Rehabilitation and Sub Acute Care. The Discovery Health experience

Transcription

1 Rehabilitation and Sub Acute Care The Discovery Health experience

2 Agenda The Context The Discovery Health Journey The Discovery Health model The Lessons learnt

3 The context Severity of condition Complex disease Functionality impaired Complex disease (outliers) Uncontrolled disease or unusual combination Significant but simple diagnosis Controlled combination (HIV, Oncology, ESRF) Well but at risk Due to lifestyle/somatic diagnosis (Obesity cholesterol HT) Healthy Displays wellness promoting behaviour Frequency of condition Source: Population Segmentation to Provide better Health Care for all: The Bridges to Health model. Joanne Lynn, Barry M Straube et al.

4 The ICEBERG Complex disease Functionality impaired Complex disease (outliers) Uncontrolled disease or unusual combination Significant but simple diagnosis Controlled combination (HIV, Oncology, ESRF) Well but at risk Due to lifestyle/somatic diagnosis (Obesity cholesterol HT) Healthy Displays wellness promoting behaviour Using Population Segmentation to Provide Better Health Care for All: The Bridges to Health Model (Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services) Only 2% of members account for +/-20% of scheme (population) Healthcare expense We need to proactively manage the 2% of members at risk of being the highest future cost drivers We set out to develop a program to: Identify the future high cost drivers Coordinating the Clinical & Psychosocial needs of high risk members Reduce Hospital cost (readmissions, beddays) 50% 40% 30% 20% 10% 0% 0% 0% 0 -No or Only Invalid Dx 20% 2% 1 -Healthy Users 26% 8% 44% 41% 2 -Low 3 - Moderate % Members % Money 8% 26% 2% 21% 4 -High 5 -Very High

5 Presentation by courtesy of Belinda Richards as presented at rehabilitation and allied services workshop. Views do not necessarily reflect those of the IUSS working group, National Department of Health, or CSIR The Care Coordination Programme - holistically managed treatment program Home Home based care Hospital admissions reduced Multiple hospital admissions Care recruiter & Care Acute Hospital coordinator Sub-acute unit Discovery Health Nurses Discovery invests in service hubs with providers.

6 THE JOURNEY

7 What is Sub-Acute Care? Exclude What is NOT Sub-Acute Care? Include Literature Classify LOC 1 LOC 2 International Definitions SA Context

8 Continuum of care ACUTE INPATIENT CARE Mental health SUB-ACUTE INPATIENT CARE ICU High Care General Ward DAY CASES Rehabilitation Convalescent Care Terminal Care Home Based Care Presentation by courtesy of Belinda Richards as presented at rehabilitation and allied services workshop. Views do not necessarily reflect those of the IUSS working group, National Department of Health, or CSIR S T E P D O W N Less Skills, more hands less cost Outpatient care

9 Actual Continuum of Care in SA ACUTE INPATIENT CARE Mental health SUB-ACUTE INPATIENT CARE ICU High Care General Ward DAY CASES Rehabilitation Convalescent Care Terminal Care Home Based Care Acute Rehabilitation Presentation by courtesy of Belinda Richards as presented at rehabilitation and allied services workshop. Views do not necessarily reflect those of the IUSS working group, National Department of Health, or CSIR S T E P D O W N Sub- Acute Beds (tariff) Less Skills, less cost, More hands Outpatient care

10 Start with: Terminology & Definitions Sub-Acute Care Rehabilitation Acute Rehabilitation Non-Acute Care Convalescent Care Step Down care Frail Care

11 Sub-Acute Care Subacute: Rather recent onset or somewhat rapid change. The term "subacute" is used in contrast to acutewhich indicates very sudden onset or rapid change and chronic which indicates indefinite duration or virtually no change. A chronic condition is one lasting 3 months or more, by the definition of the U.S. National Center for Health Statistics. In ancient Greece, the "father of medicine" Hippocrates distinguished diseases that were acute (abrupt, sharp and brief) from those that were chronic. This is still a very useful distinction. Subacutehas been coined to designate the mid-ground between acute and chronic. (emedicinehealth) Sub-acute care is a level of care needed by a patient who does not require hospital acute care, but who requires more intensive skilled nursing care than is provided to the majority of patients in a skilled nursing facility. (Californian DOH) Sub acute care comprehensive goal-oriented inpatient care designed for a patient who has had an acute illness, injury, or exacerbation of a disease process; it is rendered either immediately after or instead of acute care hospitalization, to treat specific active or complex medical conditions or to administer any necessary technically complex medical treatments in the context of the person's underlying long-term condition. (Dorlands Dictionary) Sub-Acute Care: Care given to patients who require less than a 30-day length of stay in a hospital and who have a more stable condition than those receiving acute care. (Delaware Healthcare Association Glossary of Health Care Terms and Acronyms)

12 Rehabilitation (and acute rehabilitation) Rehabilitation: The process of restoration of skills by a person who has had an illness or injury so as to regain maximum self-sufficiency and function in a normal or as near normal manner as possible. For example, rehabilitation after a stroke may help the patient walk again and speak clearly again. Rehabilitation(re hə-bil ĭ-ta shən) the process of restoring a person's ability to live and work as normally as possible after a disabling injury or illness. It aims to help the patient achieve maximum possible physical and psychological fitness and regain the ability to be independent. Rehabilitation: To restore health following an accident, injury or illness. Acute Rehabilitation: Early rehabilitation phase as soon as medically stable. Primary emphasis is to provide intensive physical and cognitive restorative services in the early months following injury. Typical stay 3-4 months (short term). Based in medical facility.

13 Other Non-Acute Care: Any health care establishment, whether of a multidisciplinary or a specifically nursing nature, providing care after or instead of acute hospitalisationto an in-patient either following an acute illness, injury or exacerbation of an existing illness or as a result of a longstanding chronic condition, and may include sub-acute care, rehabilitation care, step-down care, hospice care, convalescent care and long-term care. REGULATION R187 of the Provincial Department of Health of the Western Cape Convalescent Care: Term often used for short-term custodial care and refers to a "recovery" period after an illness or injury when some assistance may be needed that does not require skilled care. Step down care: A ward or section of a ward in a hospital that is devoted to delivering sub-acute care to patients following a period of acute care. (Blue Cross) Frail Care: No uncontrollable condition requiring medical intervention

14 Statutory Requirements/Regulations Non-Acute Care: Sub-acute care, rehabilitation care, step-down care, hospice care, convalescent care and long-term care = Department of Health Frail Care: Departments of social development Accreditation process: (COHSASA not mandatory) Structural requirements, equipment etc. Protocols processes etc. Services - Staff ratio etc. Licensing process: (DOH - mandatory) Annual process Specifies number of beds (Certificate states: Number of beds -rehabilitation beds, convalescent beds, frail care beds, hospice beds ) No Boundaries Admission = Extended stay (Frail care) Poor regulations No minimum standards of facilities (Members at risk)

15 Historic Response Current accreditation & licensing processes does not provide all the answers Inconsistent between provinces No clear/visible differentiation of services (rehab bed vs. hospice) Impossible to match the burden of illness (demand) with appropriate service (supply) Accreditation does not imply ongoing licensing License does not imply the kind of service In an industry which is so loosely defined, Interest groups (facilities, organisations, providers, funders etc.) create and use their own definitions

16 THE DISCOVERY HEALTH MODEL

17 Health Measurement for Care Management Using the International Classification of Functioning Codes Use of the ICF to quantify health information Jiro Okochi (1), Tai Takahashi (2),Kiyoshi Takamuku (3) (1) Tatsumasnosato Geriatric Facility (2) Tai Takahashi International University of Health and Welfare (3) Association of Geriatric health care facilities 2. Reviewed international experience Univ.-Prof. Dr. Günter Neubauer The Classification System of Rehabilitation Treatment Groups (RTG) 26th PCSI-Conference 2010 in Munich IfG Institut für Gesundheitskökonomik IfG Institut für Gesundheitsökonomik

18 Spectrum of Care Facility Acute Hospital LEVEL OF CARE Intensive Care (ICU) High Care General ward Acute Rehabilitation Hospital ICU/High Care Rehabilitation General Rehabilitation Care Rehabilitation/Mobilising Care Sub-acute Hospital Hospice Convalescent Care Terminal/Palliative Care Respite Care Frail Care Terminal/Palliative Care Convalescent Nursing Care Home Based Care Terminal/Palliative Care Respite Care Frail Care

19 Let s unpack the spectrum of Care

20 High Risk Members 50% 45% 40% 35% 30% Spread of membership vs Cost Ratio of Utilisation of Acute vs Subacute 25% 20% 15% 10% 5% Members Cost Acute Care Sub-Acute Care 0% Healthy users Low users Moderate users High users Very High users

21 Presentation by courtesy of Belinda Richards as presented at rehabilitation and allied services workshop. Views do not necessarily reflect those of the IUSS working group, National Department of Health, or CSIR Acute Hospital Long recuperation time Psychosocial regression Less focus on patient Frail Environment not ideal for Listen & Hear Learn Receive Therapy & Mobilisation Opportunity: Sub-Acute Hospital Building lends itself to Therapy & Mobilising Environment better for Psychosocial adjustment Listen & Hear Coach & learn Infrastructure Home away from home Can we change: Case management to risk management Value from sub-acute facility environment rather than from cheap bed

22 Care Coordination: Presentation by courtesy of Belinda Richards as presented at rehabilitation and allied services workshop. Views do not necessarily reflect those of the IUSS working group, National Department of Health, or CSIR Less hospital admissions ACUTE HOSPITAL Reduce readmissions HOME HOME BASED CARE Care Coordinator -Project Recruiting Nurse -Discovery Nurse Ongoing follow up Social Worker assist Terminal with are Psychosocial integration SUB-ACUTE UNIT Life Changing Acute incident E.g. Brain injury Complications of Chronic Disease E.g. Amputation

23 What happens in a service hub? Medication Admission to discharge in the Care Coordination Project Decision matrix Utilization Psychosocial Functional Self Care Acute care and audit of medical history with multidisciplinary team lead by Sub-acute GP Long term care following discharge involving healthcare providers & family

24 Matching demand and supply D e m a n d Specialised Severe disability with specialised needs Severe reversible Severe disability with significant reversibility Severe irreversible Severe disability with little reversibility Non-Severe Non Severe disability Matching Demand to Supply: Rehabilitation Facilities S u p p l y Registered Facility providing specialist care and technical equipment for the treatment of spinal cord injuries, paediatric and ventilator care Registered facility offering doctor led multidisciplinary care in either an acute or subacute rehabilitation environment Nurse led care with or without single discipline therapy within a subacute facility or at home Out-patient therapy Facility No Facility

25 Discovery Health s Care Coordination in practice Patient selection criteria: Clinical entry criteria Patient consent DH CCP network in the region Network of willing providers meeting DH participation criteria: Rehabilitation facilities Home nursing Pivotal role of Discovery Health: Care Coordinators & Recruiters Measurement and monitoring Extended discretionary funding

26 Increasing demand the pilot experience Growth in Sub Acute Admissions pilot experience

27 LESSONS LEARNT

28 Definitions Define the rehabilitation Language Standard South African definitions Applied across the industry Facilitate better understanding & communication & appropriate stimulation/provision of much needed care Define the Task What needs to be done within each building (unit) Sub classifications of facilities Based on services offered Define the Environment Uniformity across regions/provinces Standardise physical as well as service environment

29 Dr Belinda Richards Discovery health THANK YOU