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The Transformers: Institutional Options for Acute and Post-Acute Care – Role of the Physiatrist

The Transformers: Institutional Options for Acute and Post-Acute Care – Role of the Physiatrist. Bruce M. Gans, MD. What makes a smart health care system from the perspective of the patient. Patient-centered, not facility- or provider-centered

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The Transformers: Institutional Options for Acute and Post-Acute Care – Role of the Physiatrist

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  1. The Transformers: Institutional Options for Acute and Post-Acute Care – Role of the Physiatrist Bruce M. Gans, MD

  2. 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

  3. 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

  4. 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

  5. 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.

  6. 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

  7. A possible future model – the Continuing Care Hospital

  8. 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

  9. Economic Story • Need to create a new payment system • Hard to quantify the economic benefits • Fear of creating a new provider type without restraints

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

  11. Where it might go from here

  12. Impact of the CCH on physiatry practice • Clinical role and care • Teaching • Research

  13. Questions?

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