HSCI 678 Intro to US Healthcare System

The Continuum of Care

Chapter 13, 14, 15, 16 & 17

Tracey Lynn Koehlmoos, PhD, MHA

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

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

Primary Care Providersby Specialty

49%

23%

18%

10%

Internal Medicine

Pediatrics

Family Practice

Other Specialists

Other Primary Care Providers

• More than 23% of clinical PC visits are to FP’s

• PA’s, ARNP’s, Midwives, nurses, Chiropractors

Issues in Primary Care

• Access

• Availability of providers – 2:1 Specialists to PCP’s

• Reimbursement– Lower rate– Devaluing of care– Self-referral to specialists

Secondary Care

• Disease has crossed the clinical threshold

• Continuing care of chronic conditions

• In-patient, ambulatory, specialty surgery center, hospital ER

Ambulatory Visits by Physician Type

41%

23%

18%

10%

8%

All other specialists

Family Practice

Internal Medicine

Ob/Gyn

Pediatrics

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)

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)

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)

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)

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

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)

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

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

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)

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)

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

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

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

AHC Issues

• Higher Cost

• Increasingly competitive market from other specialty hospitals

• The ACH is the hallmark of US care: unlikely to change

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

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

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)

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

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.