Latest / Becker’s Healthcare Podcast / The Role of Long-Term Acute Care Hospitals and Partnerships in High-Acuity Care

Transcript

The Role of Long-Term Acute Care Hospitals and Partnerships in High-Acuity Care · Becker’s Healthcare Podcast

• 0:00
  Hello, everyone. This is Erica Spicer Mason with
• 0:02
  Becker's Healthcare.
• 0:04
  Thank you so much for tuning in to
• 0:05
  the Becker's Healthcare podcast series.
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  So today, we're going to talk about the
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  role of long term acute care hospitals and
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  partnerships in high acuity care.
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  And joining me for this conversation is doctor
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  Daniel DelPortal,
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  senior vice president and chief clinical officer at
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  Temple Health. Doctor DelPortal, it's great to have
• 0:23
  you on the podcast today. Thank you so
• 0:25
  much for being here. Yeah. Thanks so much
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  for having me on the program.
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  Really excited to have you. And before we
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  get into our conversation, I wanted to give
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  you the chance to share just a little
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  bit more about yourself and your work in
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  health care. Sure. Thanks. So, my clinical background
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  is as an emergency physician. I'm a practicing
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  ER doctor.
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  I've been a medical staff leader having served
• 0:46
  as as president of the medical staff for
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  our our hospital,
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  and am now a a clinical executive leader
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  as as the chief clinical officer of Temple
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  Health, which is an academic health system,
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  encompasses both academic and community hospitals. We've got
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  six hospitals, including our urban safety net hospital,
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  which is a level one trauma,
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  accredited burn center, transplant center. We've got an
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  NCI designated cancer center, a behavioral health hospital,
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  and a and a large primary and specialty
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  care network.
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  I specialize really in clinical operations,
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  so that includes optimizing capacity,
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  access to care, efficiency of care delivery,
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  timely progression of clinical care,
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  and then really focusing on the transitions in
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  and out of of inpatient care. So whether
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  it's through the front door of the emergency
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  department,
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  or on the back end,
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  linking patients from inpatient care to a post
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  acute network of skilled nursing, acute rehab,
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  and this interesting part of the continuum of
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  care that we're gonna be talking about today,
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  which is the, long term acute care hospital
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  or LTCH.
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  Yeah.
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  Well, it's great to learn more about you,
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  doctor DelPortal. Thank you so much for the
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  overview, and sounds like you're wearing a lot
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  of hats in your role. And I I'm
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  eager to hear,
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  kind of the role that long term acute
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  care is playing at Temple. And so I
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  I'd like to start there. You know, when
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  we think about long term acute care hospitals
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  or LTACs as many people call them and
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  the role that they play in the broader
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  continuum of care, how does that align with
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  the needs of the patients that you're serving
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  at Temple?
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  Yeah. It's it's really about what each setting
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  of care is designed to address. So short
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  term acute care hospitals, what what most people
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  think of as their local hospital where they
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  go to the ER if they got sick,
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  They're the right setting when there's a need
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  to establish a diagnosis and treatment plan for
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  emergency care, for, you know, a multi specialty
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  consultation to establish a diagnosis and treatment plan,
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  or for most surgical procedures.
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  By contrast, long term acute care hospitals, LTAC,
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  really specialize
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  in the care of patients with serious medical
• 2:50
  conditions that are gonna require extended hospital level
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  care.
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  Usually, it's more than twenty five days. The
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  average length of admission at an LTAC is
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  gonna be much longer, weeks to months, than
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  a short term acute care hospital, which typically
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  has an average length of stay of a
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  week or less for the majority of its
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  patients.
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  So the the model in many markets without
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  LTACs is is that a patient who needs
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  hospital level care
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  will stay in a short term acute care
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  hospital until that patient's ready to be discharged
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  to home, to acute rehab, to a skilled
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  nursing facility.
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  For the more medically complex patients, that can
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  be a really big transition, and it and
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  it can prolong their stay in the short
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  term acute care hospital.
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  Oftentimes,
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  that care can be delivered in other settings
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  that are specifically designed for it, like ventilator
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  weaning, tracheostomy
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  care,
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  intensive respiratory care,
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  situations where there really isn't diagnostic uncertainty,
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  but where the progression to rehab or home
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  is gonna be slow.
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  That's super helpful to know, doctor DelPortal. Thank
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  you. And so from what you're describing, it
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  sounds like some organizations,
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  they can make the short term
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  care work if they don't have an LTAC.
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  But I'm I'm sure that there's more to
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  it than that. So if if short term
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  care can provide the level of care that
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  you're describing, can you just say a little
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  bit more about where and how LTACs are
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  adding value?
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  Yeah. Absolutely. So so keeping patients in short
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  term acute care hospitals
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  longer to meet those milestones, it's gonna create
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  a few problems. The first is access to
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  inpatient care.
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  We know that inpatient capacity at short term
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  acute care hospitals is strained nationally.
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  Right? So hospital closures, including in the area
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  where I work in Philadelphia,
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  are reducing the number of available inpatient beds.
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  Some community hospitals are trimming services or or
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  even going to micro hospital models and sending
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  more patients, referring them out to tertiary care
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  centers, and that exacerbates that supply and demand
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  mismatch
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  for the inpatient beds.
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  And that all leads to prolonged boarding,
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  of admitted patients in emergency departments,
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  for hours, sometimes days, and that's a national
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  crisis that's that's well described. Mhmm. It strains
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  emergency care resources, and it makes it really
• 5:00
  challenging for hospitals to provide
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  stabilizing care to new arrivals while also continuing
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  to manage dozens of admitted patients.
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  So the longer patients with medical complexity
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  stay in short term acute care hospitals,
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  the more the community can struggle to access
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  inpatient services they need.
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  The second problem with keeping medically complex patients
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  longer in a traditional
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  short term acute care hospital,
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  for example, to wean from a ventilator, which
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  can take weeks or months, is that it
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  threatens the financial stability of short term acute
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  care hospitals, and that's based on the way
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  that hospitals are paid. The diagnosis
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  related group or DRG payments
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  to short term acute care hospitals are based
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  on a geometric mean length of stay. That's
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  a formula that minimizes the impact of the
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  outlier cases, and hospitals will get paid a
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  fixed rate by Medicare,
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  managed care, commercial insurance plans for the typical
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  duration and expenses of caring for most patients
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  with that same diagnosis.
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  So under a DRG based payment model, hospitals
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  aren't really reimbursed in a way that that
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  covers the expenses of caring for the more
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  medically complex patients,
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  and it's not hard to see how that's
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  gonna create a cycle, right, under reimbursement for
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  longer stay patients, hastens hospital closures, which strains
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  regional bed capacity like I just mentioned.
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  And finally, and I'd argue
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  most importantly from the perspective of the patient,
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  is that in areas without an LTCH level
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  of care or for patients who don't have
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  it as a covered benefit in their insurance
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  plan,
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  they can get trapped, for lack of a
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  better word, in in the short term acute
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  care hospital, which, again, is designed perfectly for
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  stabilization,
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  making a diagnosis, coordinating multi specialty treatment plans.
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  But LTACH, by contrast, is designed specifically to
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  provide the ongoing care, the ventilator weaning, respiratory
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  treatment, nutritional support, pulmonary rehab,
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  without competing for resources and time with those
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  unstable emergency patients that are always arriving twenty
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  four seven, three hundred sixty five days a
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  year at the short term acute care hospital.
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  So by moving to a setting that's designed
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  to focus on the longer term, sometimes
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  slower aspects of recovery,
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  the patient can often have a better experience
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  than if the short term hospitalization was prolonged
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  for months and months. So I'd say that
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  really LTACH serve as a bridge between the
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  short term acute care hospitalization
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  and
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  rehabilitation
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  or home or skilled nursing level of care
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  that really aren't equipped to handle the medical
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  complexity of the patients we're talking about. We've
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  sent a broad variety of patients to LTCH
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  from trauma patients to those with severe pulmonary
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  disease and ventilator dependent respiratory failure,
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  those that are slow to wean off of
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  ventilators,
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  to those requiring longer courses of antibiotics for
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  infections but that have significant
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  active comorbid illness that can't really be well
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  controlled in a nonhospital setting.
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  Yeah. Doctor DelPortal, it's a really helpful
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  it's really helpful the way that you just
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  broke all of this down.
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  It's fascinating to learn how just that mismatch
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  of patient acuity to facility,
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  how that can cascade into these areas like
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  patient access,
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  the economics and reimbursement
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  piece, and then also patient experience.
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  So, again, appreciate you digging in there and
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  elaborating a bit. And I wanna explore the
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  clinical part a little bit more too.
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  You you've mentioned some conditions that you've seen
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  patients,
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  effectively be treated for in LTCH. So are
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  there specific conditions or treatments that you've seen
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  or that you've been most surprised to see
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  LTACH handle effectively? And if one comes to
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  mind, could you just share a patient story
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  or anything that you think could help illustrate
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  that?
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  Sure. Yeah. I mean, they you look. This,
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  this was an education for me as an
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  emergency physician. I wasn't often seeing the the,
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  you know, back end of, you know, the
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  transition out of the hospital. And and over
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  the past decade or so, I've I've learned
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  about the capabilities of different facilities.
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  I think sometimes providers and patients tend to
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  lump facilities
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  together that are actually very different. For example,
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  if they think of LTCH as a skilled
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  nursing facility that handles ventilators, when it's really
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  more than that.
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  So I sometimes see physicians wanting to keep
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  patients longer in the hospital
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  for things like a tracheostomy change or a
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  feeding tube placement or because they're worried that
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  a patient may require
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  blood pressure support or even intensive care.
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  LTAC can do all of those things. So
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  many of those patients can be considered for
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  LTAC.
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  And sometimes I I have to remind, our
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  clinicians of the the sort of broad capabilities
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  of an LTCH,
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  that that they can handle.
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  You asked for a patient story. We had
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  one patient who had who had suffered a
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  really serious aortic dissection, a a tearing of
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  his main artery, and he was critically ill
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  and had to have surgery to fix his
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  aorta. And we were able to stabilize him,
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  but he ended up on a ventilator for
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  a prolonged period, and he had a doppoff
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  tube, a special kind of feeding tube that
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  skilled nursing facilities and rehabs just won't touch.
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  And so through our partnership with Kindred LTAC,
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  we were able to transfer him there. And
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  he's over the next twenty eight days, got
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  multidisciplinary
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  support. He weaned off the ventilator to breathe
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  independently.
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  He got his tracheostomy
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  removed.
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  He ultimately transitioned from the feeding tube to
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  a regular diet. He got physical therapy, and
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  he was discharged to acute rehab before going
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  home.
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  So there was a lot of hospital days
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  saved,
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  for for, you know, this patient's recovery.
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  And it was it was transitioning him from
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  the acute care short term acute care hospital
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  to a place really designed to meet his
• 10:23
  remaining needs in his recovery.
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  And, oh, I think, you know, when the
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  data I've seen, that we share within our
• 10:30
  partnership shows we're really saving thousands of days
• 10:33
  in the hospital,
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  for for patients who meet the criteria for
• 10:36
  LTCH.
• 10:37
  Yeah.
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  It's a great example, and I really appreciate
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  you sharing that, doctor DelPortal.
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  I know we're talking here about some of
• 10:45
  the clinical outcomes and, especially days saved in
• 10:48
  the hospital. But I also wanted to give
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  you the chance to highlight any other
• 10:52
  benefits to or changes in hospital operations that
• 10:55
  you've noticed as a result of getting support
• 10:57
  from LTAC partnerships.
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  Yeah. I mean, I think it's really helpful
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  to establish a partnership.
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  You know, that gives us regular reporting of
• 11:05
  metrics, including time from referral to acceptance of
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  a patient,
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  the length of stay of a patient here
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  in the short term acute care hospital and
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  how long they stay at the LTAC,
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  and also to track any readmissions.
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  You know, what are the reasons if if
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  somebody's not, successful at LTCH,
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  that that they need to come back to
• 11:24
  the short term acute care hospital. That gives
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  us the ability to share outcomes data with
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  our specialty teams that are referring patients,
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  and it helps to build confidence in the
• 11:32
  high level of care that an LTCH can
• 11:34
  provide.
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  We can identify areas of support that are
• 11:37
  needed. So, for example, having one of our
• 11:39
  pulmonologists
• 11:40
  round at the LTCH
• 11:42
  at least once a week to check on
• 11:43
  our patients, support the clinical care there, and
• 11:46
  really link back and give feedback to his
• 11:48
  colleagues about the patients that they've referred and
• 11:50
  how they're doing after hospital discharge. I think
• 11:53
  that's really meaningful for for our clinicians.
• 11:55
  Mhmm. And, look, we have a a liaison
• 11:59
  from from our LTACH partner that's dedicated to
• 12:01
  our hospital, and
• 12:02
  we can leverage our our electronic medical record
• 12:05
  and create lists of patients who may meet
• 12:07
  criteria
• 12:08
  and have them followed by that clinical liaison
• 12:10
  who works closely with our case management team.
• 12:13
  They work with our clinical staff to coordinate
• 12:15
  some of those aspects of care that I
• 12:17
  mentioned that are sometimes seen as barriers,
• 12:19
  when really they don't they don't need to
• 12:21
  be.
• 12:22
  They help support the families of patients. They
• 12:25
  offer tours of their facilities, and they answer
• 12:27
  questions so that it makes the transition from
• 12:29
  short term to long term acute care hospital
• 12:32
  less frightening and overall makes the care better
• 12:35
  coordinated. So, you know, having a a robust
• 12:37
  partnership, I think, does have a really,
• 12:39
  important impact on hospital operations and clinical quality.
• 12:44
  Doctor DelPortal, this has been such an informative
• 12:46
  conversation.
• 12:47
  I've learned a lot about the differences between
• 12:50
  short term care and what's possible in long
• 12:52
  term acute care.
• 12:53
  So with all of this in mind, and
• 12:56
  I know we've covered a lot of ground,
• 12:58
  I'd love to kind of get your forward
• 13:00
  looking perspective here. Where is the continuum of
• 13:02
  care headed, and how do you expect that
• 13:04
  LTACH partnerships like the one you've described will
• 13:07
  evolve as patient needs are growing more complex?
• 13:11
  Well, you know, I think if you think
• 13:12
  about how
• 13:14
  hospitals and health systems and the the challenge
• 13:16
  before them has evolved over time, right,
• 13:19
  you know, hospitals are being charged with doing
• 13:21
  so much more now than they were decades
• 13:23
  ago. We have community health workers that are
• 13:25
  assigned to help patients
• 13:27
  with the social barriers to health, you know,
• 13:29
  the
• 13:30
  the transportation,
• 13:31
  food insecurity,
• 13:33
  the things that that really contribute to to
• 13:35
  making them sick. We've got value based and
• 13:38
  risk arrangements now that hospitals are more financially
• 13:41
  at risk for patient outcomes like readmission,
• 13:43
  complications, and and frequent acute care utilization.
• 13:47
  And we've got shrinking margins and a reimbursement
• 13:49
  structure that isn't really keeping pace with supply
• 13:51
  and labor costs in health care. So short
• 13:54
  term hospitals can't do all that alone.
• 13:57
  Part of my job is is looking at
• 13:58
  where the gaps are in that continuum of
• 14:00
  care and finding sustainable ways
• 14:02
  to provide ongoing care outside the short term
• 14:05
  acute care hospital setting and to smooth the
• 14:07
  transitions of care. And my experience with LTCH
• 14:10
  is that they can serve as a really
• 14:12
  helpful role in bridging patients who are too
• 14:14
  sick from home,
• 14:16
  rehab, or skilled nursing, but don't really need
• 14:18
  all the resources of a short term acute
• 14:20
  care hospital.
• 14:22
  By establishing these partnerships, we we can really
• 14:24
  help patients to progress through their recovery at
• 14:26
  the same time as we can preserve access
• 14:29
  to that emergency stabilizing treatment for the communities
• 14:32
  that we're serving.
• 14:33
  And if it's put together the right way,
• 14:34
  I think it's really a win win. So
• 14:36
  I think the future
• 14:38
  of, you know, where LTACH fits in there
• 14:40
  is, you know, potentially
• 14:42
  an expanded role in, you know, offloading
• 14:45
  some of the the work that acute care
• 14:48
  hospitals, the short term acute care hospitals,
• 14:51
  are currently doing because they're we're being tasked
• 14:55
  with doing a lot more and and expanding
• 14:57
  our care beyond the walls of the hospital.
• 15:01
  It's such an important perspective that you're raising,
• 15:03
  doctor DelPortal. I know the capacity crisis in
• 15:06
  health care isn't going anywhere anytime soon, and,
• 15:09
  we know that patient needs seemingly are only
• 15:12
  growing more complex by the day. So it
• 15:15
  just kind of hearing your vision for what
• 15:18
  this would look like in action, you know,
• 15:20
  these stronger LTCH partnerships and how that can
• 15:22
  offload some burden on other areas of health
• 15:25
  care, it's fascinating to hear about. And I
• 15:27
  just wanna thank you again for for joining
• 15:29
  us for the conversation today.
• 15:31
  Is there anything that we glossed over too
• 15:33
  quickly or any final thoughts that you wanted
• 15:35
  to share with our listeners?
• 15:37
  I think only that that, you know, from
• 15:39
  the physician perspective,
• 15:41
  our physicians are so invested in in the
• 15:43
  care and recovery of their patients that they
• 15:45
  really need to have confidence,
• 15:47
  in those that are gonna take care of
• 15:48
  their patients after discharge from the hospital. So,
• 15:51
  you know, the the importance of partnerships,
• 15:54
  you know, really strong partnerships is is really
• 15:56
  that, you know, any way we can build
• 15:57
  bridges beyond our walls that touch and care
• 16:00
  for our patients,
• 16:02
  it can be really helpful to to find
• 16:04
  and address any gaps or concerns so our
• 16:06
  patients can get the care they need, and
• 16:08
  our doctors can get the feedback and follow
• 16:10
  through to know that someone that they've been
• 16:12
  so dedicated to caring for is on the
• 16:13
  right path in in their recovery.
• 16:16
  The best partnerships we have are truly focused
• 16:18
  on patients' needs, and they're attentive to those
• 16:21
  expert physician opinions and and those of other
• 16:24
  caregivers. And so, we really appreciate that. I
• 16:27
  think it's a really important piece of of
• 16:29
  this conversation
• 16:30
  is not just the existence of LTACs, but
• 16:32
  really how to establish a strong partnership
• 16:34
  with data sharing back and forth to make
• 16:36
  sure that we build that confidence and smooth
• 16:39
  those transitions of care.
• 16:41
  Well, it's been great to hear what those
• 16:43
  partnerships are looking like right now at Temple
• 16:46
  Doctor. Dell portal. So I wanna thank you
• 16:47
  again for for sharing all of your insights
• 16:49
  with our listeners and for this great conversation.
• 16:52
  Thanks again for having me. Great to join
• 16:54
  you.
• 16:55
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• 16:57
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• 16:59
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