Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2939_Библиотеки_им_академика_М_И_Перельмана

All of these changes promote the Quadruple Aim (improved quality, efciency, and patient and provider experience), with a focus on patient-centered care, which in PAC is offered at the right place, at the right time, and incorporates the wishes and goals of the patient and family. In addition, there are opportunities to reduce costs and improve population health outcomes. Caregiver burden, both for formal

Custodial care is care that is primarily for the purpose of assisting the individual in meeting personal rather than medical needs, which is not a specic therapy for an illness or injury and is not skilled care. Also, custodial care serves to assist an indi­vidual in the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, using the toilet, preparation of special diets, and supervision of medication that usually can be self-administered. Custodial care is maintenance care provided by health aides when an individual has reached the maximum level of physical or mental function. In determining whether an individ­ual is receiving custodial care, the factors considered are the level of care and medi­cal supervision required and furnished rather than the diagnosis, type of condition, degree of functional limitation, or rehabilitation potential.

• Long-Term Acute Care Hospital (LTACH)

The four settings provide an appropriate scope of services covering a range of acuity. A comparison of key components of each setting is summarized in Table2. With each step up from Home to LTACH comes a signicant increase in cost. Because of the shift to value and greater focus on reduction of post-acute care costs with evidence questioning the need of higher acuity care setting the move has been to shift to the left toward more home and home-like settings. MedPAC has proposed Site-neutral payments [1]. Site-neutral payments reect the Commission’s position that the program should not pay more for care in one setting than in another if the

care can safely and effectively be provided in a lower cost setting. This shift in acu­ity of care to lower-cost settings is illustrated in Fig.1: Acuity Push-down.

The shift away from SNF to less expensive home care is also being promoted in Bundle-based care programs, for example, orthopedists are now incentivized through these programs, which reimburse based upon 90-day costs around major

Home health services represent a key strategy in providing VBC by supporting ear­lier acute hospital discharge in a venue that is less expensive, and usually more comfortable for the patient. CMS provides strict guidelines, which must be met for care reimbursement.

Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) cover eligible home health services such as:

Usually, a home health care agency coordinates the services ordered by a physi­cian. It’s important to realize that Medicare doesn’t pay for:

personal care (like bathing, dressing, or using the bathroom) when this is the

Postoperative acute inpatient rehabilitation at an IRF may be considered med­ically necessary for individuals undergoing more than one major joint replace­ment during a single hospitalization, but Medicare and other payers typically do not consider it to be medically necessary when a single joint is replaced. Exceptions are made when the individual has a serious comorbidity or comor­bidities that result in functional decits that necessitate an acute inpatient level of rehabilitation in order to achieve a satisfactory outcome within a reasonable time period [6].

Subacute care may be used specically for rehabilitation purposes for any num­ber of conditions. In general, the rehabilitation needs of patients in these settings include fewer than three treatment modalities and most often physical therapy.

The cost of most hospital stays exceeds $2000 per day, while SNF costs are typi­cally less than a quarter of that. Because hospitalization represents the greater expense, care had been moving from the hospital setting to SNF.But organizations taking on risk for total cost of care will reduce costs further when patients are sent home, when appropriate, instead of to an SNF.For example, through a “Home First” strategy, providers now perform previously inpatient procedures, such as joint replacement, in outpatient settings from which the patient can go directly home. SNF rehabilitation stays are reduced. Paradoxically while hospitals are working toward fewer admissions, SNFs benet from increased admissions and occupancy. Direct admission to SNF was not reimbursed by CMS until recently, when the 3-day waiver, discussed below, was developed for organizations participating in risk­based, value-based care models [9]. These direct admissions for other conditions will allow SNFs an alternative opportunity to increase their occupancy rate.

In order to avoid inappropriate use of SNF, CMS put into place the 3-Day Rule in 1965. To qualify for Skilled Nursing Facility (SNF) extended care services cover­age, Medicare patients were required to meet the 3-day rule before SNF admission. The 3-day rule requires that the patient have a medically necessary 3-day- consecutive inpatient hospital stay. The 3-day-consecutive stay count doesn’t include the day of discharge, or any pre-admission time spent in the ER or outpatient observation.

While Medicare Advantage programs, and risk-bearing accountable care organi­zations (ACOs) have been able to be granted a waiver for this requirement, the Three-Day Rule remains in place for traditional FFS Medicare beneciaries. A tem­porary waiver of the 3-day rule was put into place in 2020 due to the COVID-19 Pandemic, but was expected to be reversed in 2021. This temporary waiver pro­moted hospital bed access for COVID-19 patients in 2020. Patients with COVID-19 could be admitted to SNFs, when medically appropriate, with the temporary 3-Day Waiver. The waiver is available if: (1) the beneciary does not reside in a nursing