In the postacute continuum space, long-term acute care hospitals (LTCH)

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1 Postacute CDI: An Introduction to Long-Term Acute Care Hospitals WHITE PAPER Summary: This white paper provides an overview of long-term acute care hospitals and how they differ from short-term acute care hospitals, with an emphasis on important differences in coding, reimbursement, and quality reporting measures. In the postacute continuum space, long-term acute care hospitals (LTCH) have been commonly misunderstood, as the term long-term historically has applied to long-term nursing facilities. However, LTCHs are licensed as acute care hospitals, as are short-term acute care hospitals (STCH). Due to this confusion, some LTCHs are now more meaningfully classified as transitional care hospitals. by Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS, MBA FEATURES What type of patient does an LTCH care for?... 1 How does an LTCH differ from an STCH?... 1 How does LTCH DRG reimbursement differ from STCH DRG reimbursement?... 1 New LTCH regulations to be phased in over the next few years... 3 Why postacute care is an important part of the evolving healthcare marketplace... 4 What are the LTCH quality reporting measures?... 5 What are the coding and CDI focuses in an LTCH?... 6 To qualify as an LTCH for Medicare payment, a facility has to meet Medicare s Conditions of Participation for acute care hospitals and, up until recent CMS changes, also had to have an average inpatient length of stay of 25 days. There are two basic types of LTCHs: (1) freestanding units and (2) hospital-within-a-hospital (HIH) units. A freestanding LTCH is a hospital facility, whereas an HIH can be one LTCH floor or unit within another acute care hospital. What type of patient does an LTCH care for? LTCHs are specifically designed to provide extended medical and rehabilitative care to a small subset of medically complex patients with multiple acute or chronic conditions and/or critical or catastrophic illnesses, such as organ failure. These complex patients may not be meeting their expected clinical milestones in an STCH and need a longer time to recover. These patients are also at a higher risk of readmission due to their complexity. A patient who is slowly weaning from a ventilator and has multiple existing comorbidities is an example of whom an LTCH cares for. How does an LTCH differ from an STCH? LTCHs have a different clinical mission than STCHs. STCHs stabilize and diagnose patients, initiating treatment under emergent conditions and moving patients to lower-intensity settings within an average of five days or less. An LTCH postacute setting continues the care in 1% 2% of these medically complex patients to provide the extended recovery time they require. How does LTCH DRG reimbursement differ from STCH DRG reimbursement? The LTCH MS-DRG system has the same DRG categories used by STCHs, but the severity weights and the lengths of stay per DRG are modified for LTCHs. Why? The severity weights and the length of stay per DRG in LTCHs represent the higher resource use and higher length of stay required for these complex patients who need a longer recovery time. (See Table 1.)

2 STCHs get paid an average of $5,000 $12,000 per DRG severity weight point, but an LTCH averages $38,000 $58,000 per point. The exact amount reimbursed to a specific STCH or LTCH is based on a calculated formula, which includes geographic area and wage index, whether the facility is rural or urban, whether the facility is an academic teaching facility, and multiple other calculations. So even as the LTCH severity weight appears less than the STCH s severity weight in the same DRG category (see Table 1), the LTCH s reimbursement is actually higher. LTCHs and STCHs are also assigned different length of stay averages per DRG. Using the example of DRG 207 (see Table 1), you can see that the STCH has an average geometric mean length of stay (GMLOS) of 12.2 days and an average length of stay of 14.1 days, whereas the LTCH has a short-stay threshold of 26.5 days and a GMLOS of 31.8 days. Very short stays (0 2 days) in STCHs are always under scrutiny by auditors for medical necessity, and transfer DRGs apply for more than 273 DRGs, with a calculated reduction in payment if the patient is discharged to an LTCH, SNF, or home with home health services in less than the GMLOS of the DRG. Looking again at Table 1 and the example of DRG 207, the LTCH s length of stay has an average window from 5/6ths of the GMLOS (26.5 days) to the GMLOS of 31.8 days. An LTCH is paid the full DRG at 5/6ths of the DRG GMLOS plus one day. A short -stay LTCH patient (i.e., a length of stay less than 5/6ths of the GMLOS) has a calculated reduced DRG reimbursement to the hospital. For a full list of LTCH DRGs, please reference the CMS website: Medicare/Medicare-Fee-for-Service-Payment/LongTermCareHospitalPPS/ltcdrg.html. Setting DRG Severity weight CMS baseline per 1.0 severity point STCH Approx. $6,613 LTCH Approx. $40,000 Facility-specific formula + or to baseline $5,000 to $12,000+ per 1.0 weight $38,000 to $58,000+ per 1.0 weight Short stay ALOS GMLOS Short stay = 1- and 2-day stays, and transfer DRGs GMLOS 12.2 days ALOS 14.1 days Short stay outlier threshold (5/6ths of GMLOS) = 26.5 days GMLOS = 31.8 days (*LTCH is paid the full DRG at 5/6ths of GMLOS + 1 day) DEC

3 New LTCH regulations to be phased in over the next few years As of December 2013, Congress passed new LTCH rules to be phased in over the next few years. Beginning October 1, 2015, LTCHs will be reimbursed for patient care under two payment systems. A patient must be admitted directly to the LTCH from the STCH. The two payment systems are as follows: 1) LTCH providers will be reimbursed at the full prospective payment system rate if patients have spent at least three days in an ICU or at least 96 hours on a ventilator 2) All other stays receive a per diem site-neutral payment rate By late 2020, 50% of Medicare patients must meet this new LTCH payment criterion in order for a facility to qualify as an LTCH. In addition, the rule eliminates the LTCH requirement for a 25-day average length of stay. The passage of these rules also consolidates LTCHs place and benefits to patients in the postacute continuum of care. In Table 2 below, you can see the dispositions of care for patients after short-term acute hospitalization, both within the first site of care following an acute care hospital stay and within a 90-day episode of care. Since LTCHs admit the most complex patients who require a longer recovery time to return to the highest functional level possible, the patient may then move to a lower and more cost-effective level of care in the postacute continuum when appropriate (i.e., when acute hospital care is not needed). SHORT-TERM ACUTE CARE HOSPITALS LONG-TERM ACUTE CARE HOSPITALS INPATIENT REHAB SKILLED NURSING FACILITIES OUTPATIENT REHAB HOME HEALTH CARE Patients first site of discharge after acute care hospital stay Patients use of site during a 90 day episode 2% 10% 41% 9% 37% 2% 11% 52% 21% 61% Table 2. References: Kaiser Family Foundations, 2011 statehealthfacts.org, and AARP 2011 projections. Source: 2009 Examining Post-Acute Care Relationships in an Integrated Hospital System. DEC

4 Why postacute care is an important part of the evolving healthcare marketplace Aging demographics and the incidence of chronic disease will shift some care settings, and the demand for postacute services will grow. It will be important to get patients discharged home more quickly or to appropriately coordinate delivery of postacute care across multiple care levels. For the medically complex patient who takes longer to recover and heal, an LTCH provides the appropriate daily acute medical care to support this recovery. The LTCH level of care helps control readmissions for these patients, while also controlling costs in a rapidly changing payment environment of value-based purchasing, readmission penalties, episodic bundled payments, accountable care, and risk payments. The following table (Table 3) provides an overview of LTCH capabilities. Clinical capabilities Interdisciplinary approach to care Physiciandirected care Licensure/ accreditation Other marketspecific services ICU-level special care units Telemetry Specialized clinical programs 1. Ventilator weaning 2. Multiple, severe wound care Physician-led interdisciplinary team meetings Goal-directed care plan Family participation education and training Organized and credentialed medical staff Specialty medical directors Daily on-site physician coverage Organized and credentialed medical staff Specialty medical directors Daily on-site physician coverage Outpatient wound care Urgent care capabilities Outpatient dialysis Hyperbaric oxygen 3. Multi-organ system failure 4. Post-intensive care syndrome High staffing levels, including nurse- patient ratios equivalent to ICU-level care where necessary Table 3 DEC

5 What are the LTCH quality reporting measures? CMS provides oversight of reporting of indicators in the LTCH setting. Section 3004(a) of the Affordable Care Act amended section 1886(m)(5) of the Act, requiring the Secretary to establish the Long-Term Care Hospital Quality Reporting Program. This program applies to all hospitals certified by Medicare as LTCHs. See Table 4 for a listing of the LTCH quality reporting measures: NQF measure ID Measure title FY 2015 FY 2016 FY 2017 NQF #0138 NQF #0139 NQF #0678 NQF #0680 NQF #0431 NQF #1716 NQF #1717 Not NQF National Health Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure NHSN Central Line-Associated Bloodstream Infection (CLABSI) Outcome Measure Percent of Residents or Patients With Pressure Ulcers That Are New or Worsened (Short-Stay) Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short-Stay) Influenza Vaccination Coverage Among Healthcare Personnel NHSN Facility-Wide Inpatient Hospital-Onset Methicillin-Resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure NHSN Facility-Wide Inpatient Hospital-Onset Clostridium difficile Infection (CDI) Outcome Measure Endorsed All-Cause Post-LTCH Discharge Readmission Measure Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes No Yes Yes No No Yes No No Yes No No Yes Table 4. Reference: Assessment-Instruments/LTCH-Quality-Reporting/LTCH-Quality-Reporting- Measures-Information.html DEC

6 What are the coding and CDI focuses in an LTCH? The coding in an LTCH is essentially the same as an STCH, but the LTCH s DRG focus is more consolidated there are no obstetrics, open heart surgeries, pediatrics, etc. in an LTCH setting. LTCHs top DRGs include the following: Septicemia (and continued management of sepsis from the STCH) Ventilator weaning Osteomyelitis Complex wound management and excisional and non-excisional debridement Amputations Other multiple and complex comorbid conditions that prolong a patient s recovery time In particular, because an LTCH patient may have 20 or more comorbid conditions, and a longer length of stay, a CDI specialist must be diligent and persistent in assessing all ongoing physician documentation of diagnoses, examining potential clinical correlations, and clarifying specificity in a larger medical record (which may include both electronic and paper records). Additionally, LTCHs are likely to code aftercare and complication DRGs from procedures and comorbid conditions that occurred in an STCH. When a patient is admitted to an LTCH after an STCH stay, the assessment of aftercare and any complications includes investigating whether they are linked to the original STCH episode of surgical care, and this linkage must be well understood. Finally, as most LTCH patients have had ICU time in the STCH before transfer to an LTCH, they tend to average higher severity of illness and risk of mortality scores (3 4), so all diagnoses documented must be coded to ensure an accurate observed to expected mortality rating. ABOUT THE CONTRIBUTOR Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS, MBA, is director of case management, clinical social work, and CDI programs for University of California Irvine Health. She has 44 years of nursing experience, including advanced nursing practice clinical experience as a family nurse practitioner; 32 years as a case manager; and 14 years in CDI program development and implementation. She has worked to mentor new case managers and a CDI specialist through formal education program development. De Vreugd s CDI experience includes the implementation of new CDI programs in the West Region of Kindred Healthcare in 25 facilities and six states while working with others within her company for CDI program expansion in the hospital division across the U.S. She is now expanding CDI collaboration with the University of California Irvine academic medical center and implementing an all-payer model and concurrent coding program to bring gains in observed to expected mortality data, quality review, and accurate length of stay information for the teaching programs. She earned a Master of Business Administration from the University of Phoenix in An ACDIS member since 2007, De Vreugd is currently serving her second term on the ACDIS advisory board and has worked with several ACDIS committees and task forces. DEC