LTACHs offer opportunities for patient contact
Patients have intense needs, long lengths of stay
If you’re looking for an opportunity to develop a close relationship with your patients and manage their care for weeks and months, rather than days, consider working at a long-term acute care hospital (LTACH), says B.K. Kizziar, RN, CCM, CLCP, owner of B.K. and Associates, a case management consulting and life care planning company in Southlake, TX.
"An LTACH is a wonderful opportunity for case managers who want to spend more time with their patients. It represents a big shift in the acute-care case management paradigm, where the average length of stay is three days. The short length of stay limits the opportunities case managers have to get to know their patients," Kizziar says.
In order to be certified by Medicare as an LTACH provider, a facility’s average length of stay must be at least 25 days, which gives case managers an opportunity to affect outcomes and quality of care, she adds.
"In an LTACH, case managers have patients for a longer period of time. They have the opportunity to manage the cost of care and quality of care. Most importantly, they have an opportunity to develop a relationship with the patient and the family, to educate them and be an influence to help them make educated health care decisions. In an acute-care hospital, case managers do discharge planning or utilization review, but they don’t have a lot of time to do true case management, and many patients don’t need it," Kizziar says.
LTACHs have the same licensure as other hospitals, but they are not required to have an emergency department or an operating suite, Kizziar says — just a procedures room where minor procedures can be performed.
Patients in an LTACH are very sick. They may be ventilator patients who are having a difficult time being weaned, people with serious wounds that are not healing and are too severe to permit them to be discharged to a skilled nursing facility, or patients with chronic diseases and multiple comorbidities. Many won’t be able to go home and will require placement in an alternative level of care, Kizziar points out.
"LTACHs represent a niche market for patients who otherwise would have to stay in the acute care hospital without funding or be inappropriately admitted to a skilled nursing facility," she says.
Many LTACH hospitals have adopted the long-time case management model for acute care hospitals, with nursing in charge of utilization review and social workers handling discharge planning, Kizziar says.
"The LTACH environment is fertile soil for development of a true case management program in a hospital setting," she says.
When she served as vice president of case management for an LTACH company, Kizziar set up case management programs for the company’s hospitals.
Since becoming an independent consultant, she has worked with LTACH organizations to develop case management programs, educate case management staff, and assist with ongoing case management professional growth.
In an LTACH, each patient’s care is coordinated by a team that develops a treatment plan, sets a target discharge date, and plans what has to be accomplished between admission and the potential discharge date. The objectives include immediate and long-term goals that will enable the patient to meet the discharge plan, she says.
"Case managers are truly managing the case, partnering with the physician in planning the treatment, and orchestrating the care," she says.
Most of the patients in an LTACH are covered by Medicare, which has a prospective payment system for LTACHs, Kizziar says.
"This means that management of length of stay and cost, along with quality of care, is essential. This requires intensive case management. These case managers are much more involved in the financial aspects of care than those in an acute care setting," she says.
In an LTACH, case managers must carefully monitor length of stay, because the hospital will lose money if the length of stay is too long for that DRG; and it will also be penalized if the length of stay is too short, Kizziar points out.
"Length-of-stay management is important in an LTACH setting, but when a comprehensive case management program is in place, cost and length of stay take care of themselves because of the influence of the case manager," she says.
Case managers monitor the treatment plan, making sure it’s appropriate for the patient and ensuring that the right treatment is given at the most opportune time for the patient to receive the most benefits.
They must ensure that the patient’s care is both efficient and cost-effective. For instance, they must make sure that the results of diagnostic studies are in the chart and available so that costly procedures aren’t repeated.
Much work with families required
Many patients admitted to an LTACH have so many issues that they can’t be discharged to home. This means that case managers spend a lot of time working with families to find a discharge destination that will work for the patient, Kizziar points out. For instance, LTACH case managers are challenged to find a discharge destination for ventilator-dependent patients and those who require dialysis. Many skilled nursing facilities won’t accept these types of patients because they won’t be reimbursed for their care.
"Difficult discharges are something an LTACH case manager faces every day. The majority of these patients have serious illnesses with multiple comorbidities, and many cannot go home," she says.
When a patient is to be discharged to home, the case managers work with community agencies to make sure all the resources the patient needs are in place at discharge. These resources include everything from transportation to meals to spiritual support, she says.
Case managers in an LTACH setting often provide disease management, working with patients and family members on managing chronic and comorbid conditions so the patient can avoid being readmitted to an acute care hospital, she says.
There’s not a cookie-cutter type of case management program that will fit every LTACH, Kizziar says.
"Each hospital has its own culture that has to be taken into consideration when a case management program is developed. While the principles of case management don’t change according to the environment in which it’s being carried out, the way in which case managers practice is affected by the environment in which they work," she says.
Lower CM-to-patient ratio
The case-manager-to-patient ratio depends on the program’s objectives, the severity of the patients’ illnesses and injuries, and the skills and abilities of the case managers, Kizziar says.
"One case manager to 15 patients is a guideline, but it may be more or less," she says.
"Patients in an LTACH do have intense needs. Case managers have to monitor the treatment plan at all levels, be familiar with community resources, conduct patient and family education, and take care of everything that’s needed for the patient at this level of care and after discharge. I don’t think it is possible for even an experienced case manager to provide all the services necessary for these patients and manage the care of more than 20 patients," she says.
Based on her experience with LTACHs, Kizziar recommends that the same case manager handle both utilization review and discharge planning.
"Case management as a whole encompasses both of these areas, and case managers should be doing both. Social workers are important in an LTACH environment because of family issues, education, and community needs; but rather than fragment discharge planning and utilization review, I suggest that the case manager handle both tasks and utilize social services as a professional consultant whenever it’s necessary," she says.
The idea of a long-term care hospital for patients with acute medical needs is nothing new, but there has been a proliferation of LTACHs in recent years, especially along the Northeast coast and across the South. For instance, there are more than 10 LTACHs in the Dallas-Fort Worth area alone, Kizziar says.
While a few LTACHs are operated by acute care hospitals, the majority are operated by LTACH companies, either in freestanding buildings or in space leased out from an acute care hospital and separately licensed, she says.
If youre looking for an opportunity to develop a close relationship with your patients and manage their care for weeks and months, rather than days, consider working at a long-term acute care hospital (LTACH), says B.K. Kizziar, RN, CCM, CLCP, owner of B.K. and Associates, a case management consulting and life care planning company in Southlake, TX.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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