Post-Acute

Selecting the Optimal Post Acute Next Site of Care: A Primer for Physicians

Selecting the optimal next site of care (NSOC) after hospital discharge has emerged as a core skill for physicians in the era of value-based healthcare. The challenge is that few of us have received formal training in post acute care site selection. When I meet with physicians and discuss NSOC selection, they express a clear desire for guidance on discharge planning as they work with patients, caregivers and the healthcare team. Here is a framework to assist physicians in post acute care selection within the BPCI program. 

The first step is to assemble some basic patient specific data in four areas:

  • Independence – Is the patient able to perform ADLs? To ambulate? What is their cognitive status?
  • Caregiver availability – Is a capable caregiver available?
  • Therapy needs – Is PT, OT and/or ST needed? How often and for how long?
  • Skilled nursing needs – What are the skilled nursing needs of this patient?

Let’s consider the main categories of NSOC and offer some rules of thumb in their respective selection:

Home without Part A Home Health Agency

(Patients here may benefit from select Part B services such as outpatient PT)

This can be considered if:

The patient is able to function in their home without a caregiver OR they have a caregiver who can meet their needs at home
AND
The patient does not need any therapies or skilled nursing services OR they can access needed therapy or skilled nursing services via outpatient visits.

Home with a Home Health Agency

This can be considered if:

The patient is able to function in their home without a caregiver OR they have a caregiver who can meet their needs at home
AND
The patient needs therapies and/or skilled nursing services that cannot be accessed through outpatient visits and that can be provided by a local HHA.

Skilled Nursing Facility

This can be considered if:

The patient is a long term resident of a SNF, receiving skilled nursing services
OR
The patient requires skilled nursing services and cannot receive them through a HHA, either because no local HHAs offer those services or because the patient cannot go home due to lack of caregiver availability.

Skilled Nursing Facility – Custodial Care or Assisted Living Facility

This can be considered if:

The patient is not able to function in their home without a caregiver and does not have a caregiver who can meet their needs
AND
The patient does not need skilled nursing services.

Inpatient Rehabilitation Facility

This can be considered if:

The patient needs at least two therapies
AND
The patient can tolerate a minimum of three hours of therapy per day, five days per week
AND
There is not a local SNF option that can provide the needed amount of therapy.

Long Term Acute Care Hospital

This can be considered if:

The patient requires ongoing acute medical care due to the severity and complexity of their condition (e.g., need for mechanical ventilation or high flow oxygen) that cannot be provided by a local SNF
AND
The patient is not progressing clinically in the hospital.

Ideally, NSOC decision-making is accomplished in structured dialog with the hospital team (such as in interdisciplinary rounds) after the goals of the patient and caregiver are clarified. Alternatively, effective team-based NSOC decisions can be made with less structured interactions with case managers, therapists, and others in the natural course of patient care on or around the nursing unit.

Physicians need not think that they are making post acute care decisions by themselves. Input and guidance from the patient and the team should always be sought and used to arrive at a final determination. Most importantly, as value-based care systems emerge, physicians should lead the healthcare team in NSOC discussions.

Tagged: Post-Acute