The Continuum of Care

1. The Continuum of Care Chapter 13, 14, 15, 16 & 17 Tracey Lynn Koehlmoos, PhD, MHA HSCI 678 Intro to US Healthcare System

2. Continuum of Care • Prenatal Care/Healthy Birth • Health Promotion • Primary Disease Prevention • Diagnosis of Disease • Treatment of Acute Disease • Secondary Disease Prevention • Tertiary Disease Prevention • Treatment of Chronic Illness • Rehabilitative Care • Long Term Care • Palliative Care

3. Primary Care • Diagnosis of illness, initial treatment • Episodic care for common illness & injury • Prescription drugs for common illness • Routine dental care (exams, cavities) • Diagnosis of potentially serious physical or mental health conditions that require prompt referral for secondary or tertiary care

4. Primary Care Providersby Specialty

5. Other Primary Care Providers • More than 23% of clinical PC visits are to FP’s • PA’s, ARNP’s, Midwives, nurses, Chiropractors

6. Issues in Primary Care • Access • Availability of providers • 2:1 Specialists to PCP’s • Reimbursement • Lower rate • Devaluing of care • Self-referral to specialists

7. Secondary Care • Disease has crossed the clinical threshold • Continuing care of chronic conditions • In-patient, ambulatory, specialty surgery center, hospital ER

8. Ambulatory Visits by Physician Type

9. Access to Secondary Care • Financial barriers (frequent treatment) • 99 Million Americans have chronic disease; and that number is growing! • By 2050, 167 million costing $906 billion • Secondary care also includes hospitalizations with fairly common surgeries (hysterectomy, cardiac cath, childbirth)

10. Issues in Secondary Care • Growing need • Limited access (financial, geographic, insurance) • Many diagnostic and treatment services are moving/have moved to outpatient setting. (Shift in delivery system)

11. Long Term Care • Continuous care over a period of at least 90 days for acute and chronic conditions • >12 million need LTC in US population • 50% <65 yrs. (40% working adults, 3% kids) • Includes mental and developmental disabilities • Two measures: • ADL’s: Activities of Daily Living (basic tasks) • IADL’s: Instrumental Activities of Daily Living (more complex social tasks, household chores)

12. Need for LTC • Expected to increase over 30 years • Baby Boomers • Life saving medical advances • Low Birth Weight babies • Accident and injury victims • Congenital and Disabling conditions (Cystic Fibrosis, Polio/Post-Polio)

13. Long Term Care Providers • Informal—7 million unpaid caregivers in US • 75% women, 35% older; 10% left employment • 33% poor health; 80% give 4 hours or more daily • Formal—Majority LTC is non-clinical • Home health aid, visiting nurse, social worker • Adult Daycare Provider, OT, PT, Speech Ther. • Assisted Living, nursing home, shelter, senior centers

14. Home Health Care • Majority of HHC is for LTC unrelated to a hospitalization • 25% of HHC agencies are hospital based • Geographic variation • Increased access via Medicaid Home and Community Based Services Waiver program (OBRA 1981)

15. Nursing Home Care • Residential population, 1.6 million • Majority are elderly patients • Some 2 million stay-and-go each year • Various classifications (SNF, Rehab, Assisted Living) various reimbursement schemes • Most nursing homes and ALF are privately owned

16. Intermediate Care Facilities • Developmental disabilities (mental retardation) • ICFMR since 1971 (now, >5000) • Nursing, social, therapeutic services • about 160K enrollees, majority adults • Highest per capita expenditure of Medicaid • $75,254 for 1998 • About 6.7% of all Medicaid expenditures

17. LTC focusing on Elderly • PACE/SHMO’s community based to monitor potentially frail elderly for nursing home (PACE—low income) • Pooling of social and health services • Avoid hospitalization/institutionalization • Medicare, Medicaid funding (some beneficiary funding for SHMO’s)

18. LTC Financing • Medicare: 10% of all Nursing Home care • Medicaid: About 50% of Nursing Home care • “Spend down”—elderly patients resources get depleted during nursing home care • Monthly charges for NH: $3,900 (2002)

19. LTC Summary • Some 12 million Americans require LTC services (many face financial barriers) • What part of health service system should be responsible for providing and paying for LTC? • Increasing need, no public policy reform in place

20. Tertiary Care • Highly specialized, procedurally intensive inpatient care that may require a prolonged LOS. $$$$$$ • Examples: • CABGs, Joint replacement • Quaternary care (new term) • Academic Health Centers • Burn Unit, Regional Trauma Center, Transplant Services, NICU

21. Providers • Specialist and sub-specialist who focus on one system, one organ, one disease • Academic Health Center • Highest level of care, largest uncompensated care (44% of all uncompensated care) • Major training site of physicians • Lots of public funding • Admit high numbers of indigent patients • All undergrad, 60% Grad medical education • Research, research, research

22. AHC Issues • Higher Cost • Increasingly competitive market from other specialty hospitals • The ACH is the hallmark of US care: unlikely to change

23. Palliative Care • Palliative/Hospice Care: Care provided to ease the pain and stress of a terminal condition when no other medical or surgical intervention is available. • Includes home health, freestanding hospice center, prescription drugs, counseling, social services, therapy • Access requires physician certification of life expectancy < 6 months

24. Hospices • About 3,200 in US (2002) • 72% Not-for-Profit • Medicare is largest payer ($5,185 per capita) • 19% <65 years; 27% >85 years • Median time in Hospice care: 36 days • Survival time is related to illness

25. Appropriate Use and Other Issues • Impossible to accurately predict point of death • Futile Care: technological advances allow us to prolong life • Lack of health insurance can bar access • Can be misapplied when there is no hope • Physician Assisted Suicide • Supreme Court 1997—No right to PAS • Oregon: Death with Dignity Act (1994)

26. Palliative Care Summary • Combines all services for end of life care • Medicare pays for 80% of Hospice care • More aged citizens, more need for palliative care • Other end of life issues arise in any discussion of palliative care

27. Continuum of Care Summary • Continuum starts with prenatal care and healthy birth and ends with Palliative Care • It is possible to enter the continuum at any of the many steps depending on the illness or cause of injury • Many people are denied access to any step in the continuum because of financial constraints.