Long-term hospitals promise better LOS, but are they good for patients?
Some swear by long-term care hospitals as solution to overcrowded ICUs
Less than a decade ago, critical care nurses saw little hope for achieving better lengths of stay for their most critically ill patients. Out comes were poor and mortality rates high. Physicians had no choice but to keep patients in the intensive care unit for months, attached to ventilators and heart monitors. Today, nurse managers at some hospitals are exploring a new option for managing these difficult patients. Long-term acute care hospitals (LTACHs) are being touted by advocates as case management solutions to the nursing care needs of long-term patients and their families. And they’re generating a following among veteran ICU nurses who say they see LTACHs as a long-overdue response to overcrowded, inefficient ICUs.
"For nurses, it’s the future of case management in critical care," says Janie Carver, RN, president and chief executive officer of Dubuis Health System in Houston. But how well are dedicated LTACH programs performing as a step-down option to ICU care? Are they suitable destinations for patients who need high-intensity care but don’t necessarily require the level provided by conventional ICUs? Should nurse managers advocate for the creation of an LTACH as a step-down at their hospitals?
On the surface, LTACHs sound like an idea hatched by administrators to curb costs under managed care. But "they’re actually designed specifically to be a patient-management model," Carver says. A year ago, Dubuis opened one at each of six medical-surgical hospitals owned by Houston’s Sisters of Charity Health Care System. Each LTACH averages about 28 beds and is Medicare-certified as a separate acute care facility.
LTACHs’ growth hampered by dearth of data
Growth in the field is hampered by a lack of sound data on LTACHs’ clinical effectiveness, and no peer-reviewed research thus far exists about how they should operate or their value in intensive care. Nevertheless, LTACHs are likely to be future referral settings for many nurse managers, experts say, chiefly because the concept makes patient care sense. A hospital within a hospital, an LTACH operates with a separate medical staff, employees, administration, food service department, and Medicare identification number. In most cases, nursing staff aren’t affiliated in any way with the host hospital’s clinicians.
The LTACH concept is foreign to acute care nurses. "To most of us in inpatient medicine, it’s a relatively new idea," says Carver, who has spent her career in acute care and came to LTACH medicine a year ago. In fact, LTACHs are so new, they have yet to achieve any significant reputation for positive outcomes and efficiency.
A growing body of anecdotal information, however, seems to suggest LTACHs offer many hard-pressed ICUs a viable option in critical care patient management. About 200 licensed and accredited LTACHs dot the map nationwide, according to the Long Term Acute Care Hospital Association of America, the industry’s main trade group based in Washington, DC. Another is the National Association of Long Term Hospitals in Boston.
Most LTACHs operate either near or within a larger hospital due to Medicare stipulations, and they accept physician referrals from neighboring facilities. By some estimates, the majority are housed near or within general hospitals and at least half are operated by large, for-profit chains.
Ranking somewhere between an ICU and a medical-surgical unit in staffing and equipment, the LTACH links the ICU to other in-hospital units such as general medical wards and skilled nursing facilities. "It completes the continuum- of-care model for critically ill patients," explains Lyndean Lenhoff Brick, JD, a senior vice president with Murer Consultants in Joliet, IL. The term for LTACH aptly describes the emphasis on "rendering acute care in a long-term care setting that is distinctly different from an SNF yet isn’t a traditional ICU," says Brick, who is regarded as one of a handful of LTACH experts in country.
For ICU nurse managers, the presence of an LTACH hospital in the community offers distinct advantages. For one, an LTACH ensures that a critically ill patient gets an equivalent or nearly equivalent level of care found in an ICU but with a mixture of highly personalized long-term care. The medical care includes:
• a high staff-to-patient ratio;
• close, around-the-clock patient clinical monitoring and supervision;
• specialized high-intensity care rendered by board-certified intensivists and pulmonologists;
• close involvement with the patient’s family in private-room settings;
• experienced, ICU-credentialed nurses and an interdisciplinary team of allied professionals, including physical rehabilitation therapists, social workers, and respiratory technicians;
• identical monitoring and treatment equipment, including heart monitors and oxygen respirators, as found in ICUs.
Staff-to-patient ratios higher
Staff-to-patient ratios are difficult to determine in LTACHs, says Carver of Dubuis, because of the varying clinical regimens and resource intensity used in treating individual patients. But they are generally considered higher than those in most medical-surgical units and much higher than those in SNFs. The ratio at St. Elizabeth Ann Seton Hospi tal of Central Indiana, an LTACH in Carmel, for example, runs about one nurse for every three or four patients. (For details on St. Elizabeth Ann, see article, p. 136.)
Nursing hours per patient day as a staffing measure are better known and usually are about 10 to 13 per patient day nationally, Brick says. In comparison, the norm is about 12 to 17 hours and five to nine hours per patient day for ICUs and inpatient acute care units respectively, Brick says.
Furthermore, LTACHs offer ICU staff a referral option for long-term patients with an expected length of stay of 25 days or more, Carver says. A minimum of 25 inpatient days is a principal criterion for a physician-authorized transfer under Medicare and most commercial payers, she says.
The 25 days is an aggregate. Many patients are discharged from the ICU only to return later with related complications. An aggregate number of days is used to determine a patient’s eligibility for an LTACH. The average length of stay in an LTACH ranges between 30 and 40 days, according to national estimates.
Meanwhile, patients are assured a more personalized level of care compared with a conventional ICU. "Our medical staff makes a vigorous effort to wean patients off ventilators and get them personally involved in their own recovery. We try to get them up and walking and take them away from their beds as soon as possible," Carver says.
In the states that license LTACHs, the same Joint Commission on Accreditation of Healthcare Organizations standards that apply to acute care hospitals apply to LTACHs. However, the Oak brook Terrace, IL-based accrediting body must accredit the LTACH apart from the host hospital.
Patient acuity runs high. Most patients need some form of 24-hour life support at least at the outset. The hospitals typically admit post-surgical cardiac cases, patients suffering multisystem sepsis, iatrogenic or diabetes-linked non-healing wounds, those with severe respiratory problems such as chronic obstructive pulmonary disease, and some head injury patients.
In Dubuis’ case, some 80% are Medicare eligible, and other LTACHs acknowledge that at least 50% of cases rank among the elderly. "Most nurses that do well [in LTACHs] have a couple of years of medical-surgical experience. Others come right out of the ICU," says Melanie G. Holt, RN, director of patient care services at St. Elizabeth Ann.
For an ICU, the transfer to LTACH represents a significant reduction in patient census and overcrowding. Between 10% of ICU patients typically qualify for an LTACH. (The proportion can be higher at some hospitals depending on the level of ICU services provided in the community.) Therefore, the patient turnover and change in daily census can relieve overcrowding, especially in units of fewer than 16 beds, Brick observes.
"However, it must be made clear that in no way is the LTACH a substitute for traditional intensive care. It’s not," Carver emphasizes. "The two models serve distinctly different purposes. However, the goals of each are the same: stabilizing the patient in preparation for the next step-down level of acute care," she adds.
Medicare has recognized this benefit. The federal health care program typically pays providers on the basis of actual cost. It makes LTACH one of the few remaining cost-based reimbursements still available, Brick says. However, in July, the Health Care Financing Administration in Baltimore, MD, capped the total amount Medicare will pay for LTACHs to $21,494 per discharge. The limit is likely to be read as a disincentive to the growth of such hospitals, says Brick.
However, private commercial insurers are beginning to get into the business by contracting for per diem payments, which could lure hospitals in search of additional revenue. Payments currently range between $800 and $1,200 per day, Brick says, which compares to an average of $1,300 to $1,400 per day for a typical medical- surgical unit.
With health plans cutting back sharply on inpatient reimbursements, LTACH represents a more attractive buy under managed care, says Brick. To payers, the advantages should be apparent, she adds. By specializing in critical long-term care, the hospital has a built in critical mass in using expensive resources efficiently, which normally means outcomes are better and lengths of stay are shorter than those in ICUs.
In addition, patients are admitted under a diagnosis-specific clinical regimen, the level of specialization among physicians is clearly defined, and resource utilization doesn’t vary wildly because most patients’ conditions are known and widely treated by the hospital. "In some ways, LTACHs are specialty hospitals," Carver observes.
But how well will this distinction translate to ICU nurses? "LTACH offers expanded opportunities for traditional ICUs. It’ll be a re-learning process for many due to the different style and approach [compared with an ICU]. But the payoff comes in a high-quality level of patient-care nurse management," Holt says.
Sources
• James Marrinan, executive director, Long Term Acute Care Hospital Association of America, 1301 K St. NW, East Tower, Washington, DC 20005. Telephone: (202) 296-4446. Fax: (202) 414-9299. E-mail: [email protected].
• Lyndean Lenhoff Brick, JD, senior vice president/principal, Murer Consultants, 62 W. Washington St., Joliet, IL 60432. Telephone: (815) 727-3355. E-mail: [email protected].
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content