“Care beyond the walls of the hospital” is how one colleague refers to the long term post-acute care (LTPAC) space. Another shares that this is the space where chronic care management happens. A third says this is the “Spectrum of Care” and explains that in these settings, all kinds of healthcare and wellness happens. In the end, they are all correct. The LTPAC sector is this and so much more, and yes, there is great diversity in the caregivers and in the care provided. This diversity is what makes the naming of this sector even more challenging. After much discussion, this is why our committee will, at least for now, continue to be called the LTPAC Committee.
When the government officials wrote the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act of 2014), they understood this challenge of identifying the sector. In the end, they chose to identify four settings (shown with a red border in the picture below) and to call them Post-Acute Care (PAC). These four settings are Home Health Agencies (HH); Skilled Nursing Facilities (SNF); Inpatient Rehabilitation Facilities (IRF); and Long-Term Care Hospitals (LTCH). Three of these four are in institutional settings, meaning the individuals reside within the setting, with HH being the only exception. In the diagram below, we show these four PAC settings along with others in this space. For each, we show the numbers of providers and programs in parenthesis, using data from MedPar and CMS. This means within PAC alone, there are about 16,658 facilities providing housing and healthcare, and another 11,456 agencies providing care in the patient’s home.
There is so much more in this sector. For instance, there are other residential settings not included in the above list. Some examples include Assisted Living Facilities (ALF); Residential Behavioral Health Settings (Res BH); and even Independent Living Facilities (often within the campus of a Life Planning Community). There are also special programs to help individuals in each of these settings, such as Hospice and the Program of All-Inclusive Care for the Elderly (PACE). When we add all these programs and providers to the mix, we have over 63,000 entities represented within LTPAC.
One caveat for further clarification, which adds to the complexity within the sector, is related to Home Health. In addition to the provision of skilled care (Medicare eligible), there is also the provision of non-skilled and long-term support services (LTSS) which are not covered under most payer programs. There are also many hybrid models of care being explored to provide in-home care for individuals. Some examples include the Hospital at Home; SNF at Home; Primary Care at Home; and community based palliative care for chronic care management. Again, these programs, with their own rules, regulations, and payment models add complexity to the sector.
Payment for care in this sector comes from a variety of sources, which adds one more touch of complexity when creating any software for the sector. For instance, a majority of reimbursements for the four identified PAC settings noted above comes from Medicare or Medicaid sources. However, Medicare continues to encourage the use of Medicare Advantage (MA) payers who have greater flexibility to pay for additional services that might be needed by the individual in certain settings. According to Kaiser Institute, there are currently 3,834 such MA plans. Any given nursing home might have 50-60 payer plans active and set up within their EMR or software. The challenge from an information technology (IT) perspective is that each of these plans has their own set of rules, regulations, reimbursement methodologies, and timelines, both for care provision and for prior approval, documentation submission, and reimbursement. This diversity makes the use of robotic process automation (RPA) almost impossible, adding to the burden in LTPAC on providers and software developers alike.
For the settings outside of PAC and within LTPAC, special programs have been created to pay for some of these services, at least in some states. For instance, ALF stays are covered by Medicaid in some states but not in others and the PACE programs are only available in certain states. These state specific programs have their own timelines and rules for submission of documents. RPA is once again, very challenging in these situations.
As noted, the diagram below begins to share some of the settings and programs noted above with a very general categorization of the acuity level of individuals cared for and the relative cost of providing this care. For clarification, the costs of HH shown below include only the costs to provide healthcare. Food and housing are additional costs that are not included. However, housing within a SNF or IRF setting includes all costs, including the food and housing. In other words, with HH, a good portion of the costs are shifted to the family.
**Diagram modified, with permission from John Derr, RPH, FASCP
There are other key similarities and differences between the acute care and LTPAC settings, especially when we consider health information technology (HIT). The first difference is that acute care settings received well over $30 billion from the Meaningful Use program in order to adopt and implement EHRs. The LTPAC settings received zero dollars. Nothing. Nada.
Even so, both acute and PAC settings have implemented EHRs (note the use of PAC vs LTPAC here). Within these PAC settings, the vast majority of these EHR products are cloud based and hosted by the software vendor. Most of these products integrate with imaging, lab, pharmacy, therapy, and physician software, sending admission, discharge, and transfer (ADT) information first, and additional clinical care information afterwards. Most do not yet have good interoperability with acute care settings.
When a person goes to an acute care hospital, the goal is to keep them alive. Once they are alive and stable, it is time to move them to another, lower cost care center. When this person comes to a post-acute setting, the goal is to give them a life worth living. Although this is a philosophical difference, this also influences the focus of the EMR and the ability to easily send and receive needed data during a transition of care, which adds to the complexity of interoperability at these times.
Finally, other kinds of technology are in use in PAC settings to provide even better care to residents and patients, while also improving efficiency for the caregivers (reminder that there is a labor challenge in all healthcare settings). For instance, robots assist with meal tray delivery in several locations. Exoskeletons are used to assist with ambulation. And remote monitoring using either wearable or on-the-shelf devices are used to minimize and prevent falls through identification and early intervention of needed rehab therapy to improve strength and balance.
Yes, the LTPAC Sector is so much more than what some of us might have thought in the past. And yes, it is time for all of us to work together because we all have someone that is receiving care in this sector. Further, it is this person, at the center of care, that is most important, no matter what setting or program they are in at this moment.