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HSC 6636: Acute Care
1Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Topics
• History• Categories of Acute Care• Acute Care in Hospitals• Hospital Organization• Issues and Trends
“Over several decades, an increasing proportion of acute care has moved to outpatient settings driven by financial incentives, advances in medical technology, and physician and patient preferences.”
Text (p. 192)
HSC 6636: Acute Care
2Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
History
• The history of acute care includes themes we have seen before
• 1800s and before saw acute care primarily home-centered– Family care ‒ Non physician practitioners– Physicians ‒ Little role for hospitals
HSC 6636: Acute Care
3Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
History (cont.)
• Early 1900s saw increased roles for hospitals– Improved hygiene, asepsis, and anesthesia and
improving equipment • Improved hospital outcomes• Shifted demand for hospital services
(displacing some home care)• Displaced long term care provided in hospitals
– Solo practitioner physician—hospital relationship takes shape
HSC 6636: Acute Care
4Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
History
• WW II Era and Beyond– Increased effectiveness, availability, and demand
for acute care services, including hospitalization• Antibiotics • Health insurance• Hospital subsidies • Medicare/Medicaid
• Modern Era– Increased reliance on NP and PA– Wide range of settings for care
HSC 6636: Acute Care
5Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Categories of Acute Care
• Ambulatory – Outpatient basis w/ no overnight hospital stay– Many settings– Less of a longitudinal relationship between patient
and provider
HSC 6636: Acute Care
6Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Categories of Acute Care (cont.)
• Ambulatory Care (cont.)– Conditions for which ambulatory care has
traditionally been provided– Shifting new conditions to ambulatory status
• New technologies reduce hospitalization• Cost containment pushes “elective”
hospitalization into ambulatory arena• Reducing hospital stays pushes more follow-up
care to ambulatory setting• Managing chronic conditions reduces demands
for hospitalization for acute episodes
HSC 6636: Acute Care
7Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Categories of Acute Care (cont.)
• Ambulatory Care Statistics– 82% of ambulatory visits to physician offices– 8% hospital outpatient departments– 10% to hospital emergency departments– 3.8 visits per person per year– Highest usage from more affluent, white, women
• Also higher usage of physician offices• Less affluent rely on emergency departments
HSC 6636: Acute Care
8Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Categories of Acute Care (cont.)
• Ambulatory Care Organization– Physician offices account for majority of visits– New delivery methods often hospital sponsored to
reduce demands on hospital facilities• Walk-in clinics• Outpatient clinics• Stand-alone surgery centers
HSC 6636: Acute Care
9Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Categories of Acute Care (cont.)
• Primary Care– Expectation of longer term relationship between
provider and patient– “A person seeking medical care directly from
various subspecialists as the need may arise, but who has no principal ongoing relationship with any of them, would be using ambulatory care but not primary care.” (p. 197)
HSC 6636: Acute Care
10Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Categories of Acute Care (cont.)
• Primary Care (cont.)– Taking on increased prominence with rise of MCO– Providers include
• Physicians • Nurse Practitioners *• PAs * • Nurse-midwives
– * Can perform 75-90% of services a physician usually provides
– Some specialists may become PCP for appropriate patients
HSC 6636: Acute Care
11Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Categories of Acute Care (cont.)
• Emergency Care– Multiple roles
• True emergencies– Recognized medical specialty– Specific equipment and procedures
• Walk-in for less ill– Uninsured– Uncertain
• Resource rich primary care environment to assess patients with serious problems
HSC 6636: Acute Care
12Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Categories of Acute Care (cont.)
• Specialty Care– Care by specialists for acute conditions– Surgical ambulatory care for less debilitating
procedures• 16.4% of surgery outpatient in 1980• 63% outpatient by 2005
– Imaging services provided through• Specialty imaging practices• Physician offices
HSC 6636: Acute Care
13Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Acute Care in Hospitals
HSC 6636: Acute Care
14Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Acute Care in Hospitals (cont.)
• Behind the Numbers– Increasing population
• Admissions per person holding steady– Aging population– Crowding– Demand for outpatient services
HSC 6636: Acute Care
15Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Acute Care in Hospitals (cont.)
• Teaching Hospitals– Part of an academic medical school and/or;– Offer residency programs– May have medical school faculty on staff– Disproportionate share of uncompensated care
delivery– Mixed benefits to patients
• Much care delivered by trainees• Access to highly qualified faculty
HSC 6636: Acute Care
16Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Acute Care in Hospitals (cont.)
• Public Hospitals– Supported by government funds (in addition to
fees)• Direct operation by government• Operation by a separate government
supervised agency• Operated by a not for profit company under
contract with a government– Often serve underserved areas
HSC 6636: Acute Care
17Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Acute Care in Hospitals (cont.)
• Public Hospitals (cont.)– Typically larger when in urban areas– “Safety Net” providers– Only 2% of nation’s hospitals but provide 25% of
uncompensated care– Other community roles
• Public health• Outreach and education• Disaster planning
HSC 6636: Acute Care
18Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Acute Care in Hospitals (cont.)
• Rural Hospitals– About 2/5 of hospitals classified as ‘rural’– Much smaller than urban hospitals– Facing shifting demographics
• Older and poorer– Difficulty providing expensive technologies
• Difficulty attracting physicians– Disproportionately hit by Medicare reductions but
with some offsets
HSC 6636: Acute Care
19Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Acute Care in Hospitals (cont.)
• Multihospital/Integrated Healthcare Systems– Half of hospitals part of larger entities
• Chains or networks• Holding companies• HMO
– Network: Group of providers working together– Multihospital System: Members under the same
management umbrella• Often an ownership relationship
– Alliance: A formal organization to integrate operations of members
HSC 6636: Acute Care
20Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Hospital Organization
• Hospitals which of a wide range of services to provide– Driven by available practitioners– Needed investment– Demand & competition
• Physicians control admissions• Hospitals provide support services
– Labs ‒ Imaging– Pharmacies ‒ Facilities– Nursing ‒ etc.
HSC 6636: Acute Care
21Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Hospital Organization (cont.)
• Physician Relationships– Previous coverage– Note that physician orders for hospital services are
not paid by the physicians• Governance structures
– Traditional/departmental—dual authority structure– Divisional—more integrated support services– Independent-corporate—Medical stall a separate
legal entity– Parallel—Professionals time-share their efforts
HSC 6636: Acute Care
22Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Hospital Organization (cont.)
• Governance models can vary– Often committees with varying authority– Management staff– Executive committee– Board of directors
HSC 6636: Acute Care
23Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Issues and Trends
• Team Based Care– Construct a team focused on the patient’s needs– Leverages each member’s expertise– Minimizes distractions away from primary strength– Minimizes on-site time for office-based members
• Patient-Centered Care– Recognizes need for patient engagement– Incorporate patient preferences– Has lead to reduced aggressive treatments
HSC 6636: Acute Care
24Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Issues and Trends (cont.)
• Physician Training– New trends recognize pros and cons of managed
care trends– Emphasize continuity of care including outside of
hospital setting– Reducing residency work requirements
• Increases demands for physician extenders
HSC 6636: Acute Care
25Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Issues and Trends (cont.)
• Access to Care– Acute care providers must deal with number of
uninsured/underinsured patients– $40.7 billion cost for uncompensated care in 2004– Increasing complexity of conditions as patients
defer care
HSC 6636: Acute Care
26Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest
Issues and Trends (cont.)
• Costs of Care– Cost containment strategies addressing
• Reimbursement mechanisms• Changes to practice including managed care• More aggressive resource management
– Shifting more care to ambulatory environment– Addressing administrative complexities– Increasing use of information technologies