Whether you’re a hospitalist who works only in a hospital, a hospitalist who works only in a post-acute care (PAC) setting, or a hospitalist who works in both types of facilities, knowing about current trends at PAC facilities and what the future may hold can help you excel in your current capacity and, ultimately, improve patient care.
The Hospitalist tapped experts in the post-acute space to tell us what they thought HM should know about working in PAC – which, in many ways, is quite different from the hospital setting. Here’s a compilation of their top eight must-knows.
1. PAC settings rely more on mid-level medical staff than hospitals do.
PAC facilities employ more mid-level providers, such as nurse practitioners and physician assistants, because they can support the level of medical complexity and decision making 95% of the time, says James D. Tollman, MD, FHM, president of Essex Inpatient Physicians in Boxford, Mass. Further, they are more heavily staffed by licensed practical nurses than are acute-care settings.
A hospitalist might work at a PAC facility only several days a week. In fact, Medicare and state regulations dictate what duties physicians can perform there and how often they can see patients. The hospitalist also serves in the role of primary-care physician and specialist in this setting because none of these types of physicians are present, Dr. Tollman says.
Usually, there is no physician or nurse practitioner presence at night. Clinicians rely on nursing staff’s assessment to make decisions regarding changes in patient status during off-hours, says Virginia Cummings, MD, director of long-term care, gerontology division, at Boston-based Beth Israel Deaconess Medical Center.
Although the pace of care traditionally has been slower at a PAC facility than at a hospital, within the last few years, the pace at the former has increased. This is because newer reimbursement models are resulting in earlier hospital discharge for patients who are more acutely ill at the time of discharge. “Years ago, patients at PAC facilities needed to be seen only biweekly by a physician,” says Arif Nazir, MD, CMD, FACP, AGSF, who is chief medical officer, Signature HealthCARE, in Louisville, Ky. “Now, many need to be seen several times a week.”
2. Testing takes longer, and options are limited.
Access to some acute urgent resources such as laboratory testing, imaging tests, and pharmacy products is more challenging at PAC facilities because most of these resources are not on-site. Consequently, there is a time lag between ordering tests and new medications and implementing these orders.
“If a patient needs something performed diagnostically immediately, they usually have to be transported to the emergency room or a facility with the necessary testing equipment,” Dr. Tollman says.
“Most of the time patients in PAC settings have had their most urgent needs resolved, but they could develop those needs again,” Dr. Nazir says. “Therefore, it is important for a hospitalist taking care of a patient to be aware of what resources a facility has available promptly.”
However, Paul T. Liistro, managing partner, Arbors of Hop Brook Limited Partnership in Manchester, Conn., and Vernon Manor Health Care Center in Vernon, Conn., and administrator, Manchester Manor Health Care Center, notes that it’s possible for a laboratory service or mobile diagnostic unit to provide laboratory testing or certain imaging at a PAC facility. More-involved diagnostics, such as an MRI or a PET scan, typically require testing at a remote location.
“But, as technology improves and big machines become smaller machines and staff members become more proficient in their positions, PAC facilities will have the ability to care for more patients efficiently,” Mr. Liistro said.
3. Patient populations mainly include rehab and terminally ill patients.
Patients are typically sent to a PAC facility either to recover from an illness or injury or because they are chronically ill and have exhausted treatment options. Regarding the latter, “They are mostly there for palliation; we don’t perform daily tests or prescribe aggressive medications on these patients,” Dr. Nazir says.
Dr. Cummings explains that PAC clinicians go through “the dying process with the patient.”
“They may or may not have assistance from hospice organizations,” she says, “and when they don’t, [hospitalists] take on the role of palliative-care providers.”
Dr. Cummings has seen an increase in psychiatric patients entering PAC facilities.
“Many patients with chronic psychological problems are aging, and there are fewer inpatient psychiatric beds available to those with concurrent medical and psychiatric problems,” she says. Much of this work is now being done in PAC settings.