The Transformers: Institutional Options for Acute and Post-Acute

Care – Role of the PhysiatristBruce M. Gans, MD

What makes a smart health care system from the perspective of the patient Patient-centered, not facility- or provider-centered Caring about the patient as an individual in the context

of family and community Caring about function and quality of life as well as

health status Protecting the patient’s economic and human resources Safe, high quality care Long-view as well as short-term perspective

Care coordination – Why is it so hard?

Dollars do not drive us there (at least not very far) Few acute care professionals really know the long-term

consequences of disabling conditions Few acute care professionals really understand the

different post-acute settings

Care coordination – Why is it so hard? (continued) Decision tools and decision makers tend to be biased◦ Insurance company tools (Milliman, InterQual) ◦Clinicians who are highly invested and motivated by providers

they work for or with Patients and families are largely not well informed and

able to execute good choices based on adequate information about the post-acute settings

Pressure of time forces “haste makes waste” choices

Simple minded solutions

Plan Ahead Anticipate future needs (both short- and long-term) Put people who know and understand the long-term

into the acute (and hyper-acute) care settings to do a and b above

Rely on best available evidence and expert clinical opinion

Learn from the long-term consequences of near-term decisions and hold near-term decision makers accountable for the long-term outcomes.

Examples of practice and institutional models in operation Health systems that organize the continuum of care as a

whole Rehabilitation Joint Ventures that span the whole

continuum of care Embedding physiatrists into the acute care enterprise Teaming physiatrists with clinical liaisons

A possible future model – the Continuing Care Hospital

Technical Story

New provider type Operational attributes of LTCH, IRH/U (IRF) and SNF Single medical decision maker Single payment (prospective) based on patient

characteristics Single outcome measurement system Internal freedom to flex resources to patient need Elimination of regulatory requirements that bar any of

the above

Economic Story

Need to create a new payment system Hard to quantify the economic benefits Fear of creating a new provider type without restraints

Political Story

Included (twice) into ACA Opposed (or at least not supported) by CMS A dolphin caught in the ACA Tuna Net?

Where it might go from here

Impact of the CCH on physiatry practice

Clinical role and care Teaching Research

Questions?