Unfortunately, hospitals and post-acute facilities have had few incentives to coordinate patient care. As a result, post-acute patients were at high risk for readmission, with 15 to 28 percent returning to the hospital within 30 days.
That changed in 2014, when Congress passed legislation to penalize post-acute facilities with high readmission rates. The program is set to launch in October 2018 and is prompting many post-acute providers to rethink care coordination and delivery.
I stepped onto the front lines of that transformation when I left my hospitalist job to become the first on-site medical director at a nearby LTAC. In today's post, I'll share what that change has meant for both patient care and the facility itself.
A New Approach
FutureCare is a post-acute provider with 13 locations in the Baltimore-Washington, D.C. area. The Irvington campus offers a wide range of services, from short-term rehabilitation to a 50-bed progressive pulmonary (ventilator) unit. We receive patients from surrounding hospitals as well as Saint Agnes Hospital, which is located just two miles away.
The patients in the ventilator unit are especially fragile and complex. Most have been at the facility for six to 12 months following a complicated hospital course. Tracheotomies and feeding tubes are common in this population.
Previously, the ventilator patients were cared for by individual internists, who were also juggling office and hospital visits. As a result, nursing staff had difficulty communicating with the physicians.
Throughout the first half of 2015, the ventilator unit had an above average number of readmissions per month. Many of these patients were sent back to the hospital for fairly routine issues like fever, abnormal labs or diarrhea. These problems might have been managed at FutureCare had the right expertise been available.
That's where I come in. In 2015, FutureCare, Irvington asked Vituity to provide medical direction for the ventilator unit. Being familiar with my work as hospitalist medical director at Saint Agnes (where CEP manages the emergency department), they asked me if I might be interested in heading up this practice.
The Doctor Is In
In August 2015, I became medical director of the ventilator unit. In this role, I serve as primary physician for all of the patients (other than a handful who contractually must maintain their outside doctor). I'm on-site Monday through Friday and available to patients, families and staff.
Having a dedicated medical director on site has many benefits. For one, we're now able to provide a true medical home. Before a patient arrives, I work with the sending hospital to promote a smooth transition. (For example, we follow a protocol around catheter removal to ensure that the patient will be able to void independently within the first three days of admission.)
Once the patient arrives, they receive consistent day-to-day care. Interactions that used to happen monthly are now part of the routine. I round frequently to examine tracheotomy sites, central lines and IV catheters. I order recommended preventive screenings and track compliance with disease-specific core measures.
If an issue comes up, I can go right to the bedside and manage the situation. Having a physician on-site increases our clinical capabilities considerably. We can now administer IV antibiotics and fluids and read routine X-rays and EKGs. I'm also working to assemble a specialty call panel (gastroenterologists, infectious disease, etc.) who can deliver advanced care at the bedside.
Of course, sometimes we still have to send a patient to the hospital for advanced tests or treatments. In these cases, I can often work with the ED team to avoid an inpatient admission. This is a tough line to walk, because the ventilator patients look pretty frail. It takes a lot of trust for the ED physician to simply order a CT scan or transfusion and then transfer them back. This is where having an existing relationship with the ED physicians really comes in handy. I also attend monthly emergency department meetings to build relationships and provide education about our patients.
When a ventilator patient does need to be hospitalized, they often end up being cared for by my former colleagues at Saint Agnes. This is great, because the doors of communication are already open. Working together, we can often reduce length of stay — and get the patient back to FutureCare before their Medicare inpatient coverage runs out.
So far, FutureCare's investment appears to being paying off. Hospital readmissions from the Irvington facility have decreased by 300 percent. The remaining admissions have been for true medical emergencies (e.g., status epilepticus or pneumothorax) that couldn't be safely treated in an outpatient setting. While I don't have any data on cost savings, administrators have suggested that it could reach one million dollars within the first year.
The new arrangement has also been a boon for our nurses, therapists, case managers and the rest of the care team. At first, they were understandably nervous about treating vulnerable patients on the unit. But after getting to know me and working with me through a few cases, their trust increased. I think they now realize that I'm a "safety net" who can step in during a crisis. I'm available if they need a quick medication ordered or just have a question about a patient. It seems to ease their anxiety and make their work more satisfying.
Finally, full-time physician coverage has allowed us to engage more meaningfully with patients and their loved ones. Family members can stop by my office any time with questions or concerns. When appropriate, we initiate goals of care conversations. This has helped some of our patients with end-stage-disease make their wishes known and transfer to hospice care (which they can receive at our facility).
We're now able to provide care that is high-quality, comprehensive and truly team-based. Each week, our entire care team (medicine, nursing, case management, therapy, nutrition, activities, etc.) meets to review about six to 10 patients and update the plan of care. Families are invited to participate in person or by conference call. In addition, I round on patients three times a week with our unit nurse manager and FutureCare's directors of nursing and respiratory therapy.
It's been an exciting journey with FutureCare. Thanks to the successes achieved at Irvington, the company is partnering with Vituity to manage a sub-acute unit at a second facility.
Personally, I'd like to say that post-acute care has been a very fulfilling transition. My job offers plenty of clinical challenges while allowing me to maintain a positive work-life balance. I would highly recommend post-acute care to hospitalist and internal medicine physicians who are seeking a fulfilling first job or career transition.