Chapter 5
Subacute and
Postacute Care
Learning Objectives
1. Define and describe subacute
and postacute care
2. Identify where subacute care fits
in the continuum of care
3. Identify sources of financing for
subacute care
Learning Objectives (continued)
4. Identify and describe regulations
affecting subacute care
5. Identify and discuss ethical issues
affecting subacute care
6. Identify trends affecting subacute
care for the near future and the
impact of those trends
What is Postacute Care?
Postacute care:
Improves transition from hospital to
the community
Provides services to patients needing
additional support following
discharge from the hospital
Postacute Care Providers
Include:
Inpatient rehabilitation facilities
Long-term care hospitals
Skilled nursing facilities
Home health agencies
What is Subacute Care?
Comprehensive inpatient care
Comes after, or instead of, acute care
Between acute and long-term care
Usually for a defined period of time
Developed largely for cost savings
Philosophy of Care
Four types:
Transitional
General
Chronic
Long-term transitional
Ownership of Subacute Facilities
Mostly freestanding SNFs (two-thirds)
• Rehabilitation focus
Hospital-based
• Medical focus
Many owned by corporate chains
Services Provided
• Rehabilitation • Chemotherapy
• Physical therapy • Parenteral nutrition
• Occupational therapy • Dialysis
• Respiratory therapy • Pain management
• Cardiac rehabilitation • Complex medical care
• Speech therapy • Wound management
• Postsurgical care• Ventilation care
• Other specialty care
Care Planning
Focus on quality of care and outcomes
Initial assessment
Interdisciplinary team
Weekly team conferences
Ongoing evaluation
Case Management
Focus on efficiency, cost-effectiveness
Manage resources to optimize outcomes
at lowest cost
Case managers may be:
• “External” – hired by payer
• “Internal” – hired by provider
Consumers of Subacute Care
Post hip-replacement surgery
Spinal cord or brain injuries
Strokes
Cancer
AIDS
Wounds
Cardiac recovery
Respiratory ventilation
I.V. therapy or feedings
Market Forces
Cost-saving efforts
Managed care
Choice
Regulations
Purpose of regulations:
Care is safe and of high quality
Care is not unnecessarily expensive
Services are uniformly accessible
Rights of workers are protected
Types of Regulations
Medicare
OBRA
Other – similar to other providers
Accreditation
Joint Commission
CARF International
NCQA
Financing Subacute Care
Reimbursement Sources:
Medicare – two-thirds
• Pays as SNF
Other third:
• Managed care
• Medicaid
• Private insurance, self-pay, and other
Staffing
Interdisciplinary team:
Program administrator
Physicians
Nursing
Other professional staff
Nonlicensed staff
Legal and Ethical Issues
Meeting regulations
Liability issues
Management Qualifications
Licensed by the s ...
4Seeking an Effective Care ContinuumLearning Objective.docxblondellchancy
4
Seeking an Effective Care Continuum
Learning Objectives
After reading this chapter, you should be able to:
• Identify programs that address the health issues surrounding workplace accidents.
• Assess the need for a continuum of care that comprises a comprehensive approach to
health care for vulnerable populations.
• Identify the preventive care services available to vulnerable populations.
• Examine the treatment services available to vulnerable populations.
• Explain the options that vulnerable populations have for accessing long-term care.
Courtesy of Kurhan/Fotolia
bur25613_04_c04_111-148.indd 111 11/26/12 10:30 AM
CHAPTER 4
Critical Thinking
OSHA provides many programs to ensure workers’ health and safety. Is there a similar program for
health care elsewhere? If not, could OSHA be used as a model to create or redesign existing programs?
Introduction
Introduction
Workplace injuries, deaths, and work-related illnesses cost the United States approximately $693.5 billion a year (National Safety Council, 2009). The Occu-pational Safety and Health Administration (OSHA), established in 1970,
ensures safe and healthy working conditions for men and women by setting standards
and providing training, outreach, and education. In other words, OSHA focuses on the
prevention of injuries by regulating the workplace.
In contrast, workers’ compensation programs, which are administered through the
Department of Labor, help workers who have already sustained a work-related injury or
an occupational disease. These programs focus on wage replacement, medical treatment,
and rehabilitation services coverage. Employers pay into the workers’ compensation
programs through companies that work to mitigate costs to insurance companies, called
insurance underwriters, or government programs to help cover these expenses. Although
paying into the national workers’ compensation program represents a significant expense
for employers, lost employee productivity is more costly. To minimize workers’ compen-
sation and lost productivity expenses, many employers have preventive workplace safety
programs that include educational sessions on safety and even posters with images and
safety messages to remind workers of best practices for safety. These preventive programs
aim to minimize risks both to the workers and the employers. Some of these programs
are available through OSHA, the national programs for workers’ compensation, or their
company insurance or liability underwriter.
Workplace safety programs and workers’ compensation programs provide a continuum
to address the health issues surrounding workplace accidents. From prevention to treat-
ment to rehabilitation to return-to-work, workplace safety and workers’ compensation
programs address the specific health care needs of America’s working population. This is
one example of the way a continuum of care works and how programs can work together
to create a continuum of care. E ...
The document provides guidance for domiciliary care organizations and staff on delivering high quality end of life care for people in their own homes. It outlines six key steps in the end of life care pathway: 1) discussions as end of life approaches, 2) assessment, care planning and review, 3) coordination of care, 4) delivery of high quality care, 5) care in the last days of life, and 6) care after death. The guidance addresses important considerations for organizations and the roles of care workers at each step to help ensure people receive dignified and compassionate care at the end of life in their own homes.
Key Principles Of Person Centred Care
Obama Care Essay
What Is Self Care? Essay
Hospice And Palliative Care Essay
Access of Care Essay
Patient Centred Care Essay
The Ethics Of Care Ethics
Personal Essay: Care For Others
Person Centred Care Essay
Ethics Of Care Essay
Healthcare in the United States Essay
Managed Care Essay
Chronic Care Vs Acute Care Essay
Self Care Essay example
Infection Control In Health Care Essay
Quality Patient Care Essay
Day Care Essay
Comfort Care Advantages
Person Centred Care Essay
Continuity Of Care Essay
1.Write an essay discussing the various causes and solutions for aBenitoSumpter862
The document discusses maintaining boundaries for a correctional officer who has been threatened by an inmate. It outlines a scenario where the officer, Patricia Wilkes, was recently attacked at work and is now being manipulated by the inmate who witnessed it. The inmate promises protection if she smuggles contraband for him, and though afraid, she agrees. The presentation will discuss developing a plan to maintain boundaries in this situation, potential obstacles, and the ethical and legal consequences of not upholding boundaries. It provides an overview of the inmate manipulation scenario and topics that will be covered.
1.Write an essay discussing the various causes and solutions for aSantosConleyha
1.Write an essay discussing the various causes and solutions for a patient’s inability to pay for medications (prescriptions).
Your response should be at least 200 words in length
2. “Front desk syndrome” is a particularly troublesome aspect of patients visiting their healthcare provider. Write an essay describing this phenomena and methods to prevent or decrease its occurrence.
Your response should be at least 200 words in length.
Inmate Manipulation and Boundaries
Nicole Jones, Dionne Russell, Francisco Villegas, Lupe Silva
University of Phoenix
CPSS/430
Dr. Debra McCoy
May 16, 2022
What to Expect from This Presentation
Summary of manipulation scenario
Development of a plan for how to maintain boundaries in this situation
Possible obstacles in setting and maintaining these boundaries
Identifying ethical and legal consequences to not maintaining boundaries in this situation
Manipulation Scenario
Patricia Wilkes works as a correctional officer at Corcoran California state prison. Corcoran is a high security institution that houses some of the most violent male offenders. Patricia has worked at the institution for four years and has encountered two attacks against her from two separate inmates over a year span. Patricia is freshly returned back to work after being off for a week due to her injuries from her latest attack. The attack involved her being pushed down by an inmate, causing a sprain arm. Feeling vulnerable Patricia became friends with an inmate who witnessed the attack and promised to issue protection if she sneaks in contraband for him. She is conflicted but, because she is afraid; she agrees to do it.
How to Maintain Boundaries in this Situation
How to Maintain Boundaries in this Situation (continued)
How to Maintain Boundaries in this Situation (continued)
Possible Obstacles in Setting and Maintaining these Boundaries
Possible Obstacles in Setting and Maintaining these Boundaries (continued)
Possible Obstacles in Setting and Maintaining these Boundaries (continued)
Ethical and Legal Consequences to not Maintaining Boundaries in this Situation
Ethical and Legal Consequences to not Maintaining Boundaries in this Situation (continued)
Ethical and Legal Consequences to not Maintaining Boundaries in this Situation (continued)
Questions
References
HCA 4303, Comparative Health Systems 1
Course Learning Outcomes for Unit I
Upon completion of this unit, students should be able to:
1. Identify and explain how demographics, such as age and race, impact true access to quality care.
Reading Assignment
Chapter 1: Introduction
Chapter 2: Disparities in Health Care: Race and Age Matters
Unit Lesson
Many Americans find it difficult to even comprehend being denied access to medical care. When we are sick,
we want to see a physician, promptly receive a diagnosis, and procure the necessary treatment that will
restore us to our previous level of health. T ...
Infection control in healthcare facilities aims to prevent the spread of microorganisms between patients and staff. It is important as healthcare associated infections can significantly increase a patient's length of stay and risk of death. Standard precautions like hand hygiene and use of personal protective equipment are the primary methods for preventing transmission. Ongoing education of staff and monitoring adherence to policies is also key to effective infection control.
The Affordable Care Act (ACA) expands access to health insurance coverage and aims to reduce costs and improve quality of care. Key elements include establishing health insurance exchanges to help consumers find and buy plans, providing subsidies to help lower costs, and requiring insurers to cover pre-existing conditions. However, high medical costs and shortages of primary care providers remain challenges. The ACA invests in expanding community health centers to help address provider shortages.
4Seeking an Effective Care ContinuumLearning Objective.docxblondellchancy
4
Seeking an Effective Care Continuum
Learning Objectives
After reading this chapter, you should be able to:
• Identify programs that address the health issues surrounding workplace accidents.
• Assess the need for a continuum of care that comprises a comprehensive approach to
health care for vulnerable populations.
• Identify the preventive care services available to vulnerable populations.
• Examine the treatment services available to vulnerable populations.
• Explain the options that vulnerable populations have for accessing long-term care.
Courtesy of Kurhan/Fotolia
bur25613_04_c04_111-148.indd 111 11/26/12 10:30 AM
CHAPTER 4
Critical Thinking
OSHA provides many programs to ensure workers’ health and safety. Is there a similar program for
health care elsewhere? If not, could OSHA be used as a model to create or redesign existing programs?
Introduction
Introduction
Workplace injuries, deaths, and work-related illnesses cost the United States approximately $693.5 billion a year (National Safety Council, 2009). The Occu-pational Safety and Health Administration (OSHA), established in 1970,
ensures safe and healthy working conditions for men and women by setting standards
and providing training, outreach, and education. In other words, OSHA focuses on the
prevention of injuries by regulating the workplace.
In contrast, workers’ compensation programs, which are administered through the
Department of Labor, help workers who have already sustained a work-related injury or
an occupational disease. These programs focus on wage replacement, medical treatment,
and rehabilitation services coverage. Employers pay into the workers’ compensation
programs through companies that work to mitigate costs to insurance companies, called
insurance underwriters, or government programs to help cover these expenses. Although
paying into the national workers’ compensation program represents a significant expense
for employers, lost employee productivity is more costly. To minimize workers’ compen-
sation and lost productivity expenses, many employers have preventive workplace safety
programs that include educational sessions on safety and even posters with images and
safety messages to remind workers of best practices for safety. These preventive programs
aim to minimize risks both to the workers and the employers. Some of these programs
are available through OSHA, the national programs for workers’ compensation, or their
company insurance or liability underwriter.
Workplace safety programs and workers’ compensation programs provide a continuum
to address the health issues surrounding workplace accidents. From prevention to treat-
ment to rehabilitation to return-to-work, workplace safety and workers’ compensation
programs address the specific health care needs of America’s working population. This is
one example of the way a continuum of care works and how programs can work together
to create a continuum of care. E ...
The document provides guidance for domiciliary care organizations and staff on delivering high quality end of life care for people in their own homes. It outlines six key steps in the end of life care pathway: 1) discussions as end of life approaches, 2) assessment, care planning and review, 3) coordination of care, 4) delivery of high quality care, 5) care in the last days of life, and 6) care after death. The guidance addresses important considerations for organizations and the roles of care workers at each step to help ensure people receive dignified and compassionate care at the end of life in their own homes.
Key Principles Of Person Centred Care
Obama Care Essay
What Is Self Care? Essay
Hospice And Palliative Care Essay
Access of Care Essay
Patient Centred Care Essay
The Ethics Of Care Ethics
Personal Essay: Care For Others
Person Centred Care Essay
Ethics Of Care Essay
Healthcare in the United States Essay
Managed Care Essay
Chronic Care Vs Acute Care Essay
Self Care Essay example
Infection Control In Health Care Essay
Quality Patient Care Essay
Day Care Essay
Comfort Care Advantages
Person Centred Care Essay
Continuity Of Care Essay
1.Write an essay discussing the various causes and solutions for aBenitoSumpter862
The document discusses maintaining boundaries for a correctional officer who has been threatened by an inmate. It outlines a scenario where the officer, Patricia Wilkes, was recently attacked at work and is now being manipulated by the inmate who witnessed it. The inmate promises protection if she smuggles contraband for him, and though afraid, she agrees. The presentation will discuss developing a plan to maintain boundaries in this situation, potential obstacles, and the ethical and legal consequences of not upholding boundaries. It provides an overview of the inmate manipulation scenario and topics that will be covered.
1.Write an essay discussing the various causes and solutions for aSantosConleyha
1.Write an essay discussing the various causes and solutions for a patient’s inability to pay for medications (prescriptions).
Your response should be at least 200 words in length
2. “Front desk syndrome” is a particularly troublesome aspect of patients visiting their healthcare provider. Write an essay describing this phenomena and methods to prevent or decrease its occurrence.
Your response should be at least 200 words in length.
Inmate Manipulation and Boundaries
Nicole Jones, Dionne Russell, Francisco Villegas, Lupe Silva
University of Phoenix
CPSS/430
Dr. Debra McCoy
May 16, 2022
What to Expect from This Presentation
Summary of manipulation scenario
Development of a plan for how to maintain boundaries in this situation
Possible obstacles in setting and maintaining these boundaries
Identifying ethical and legal consequences to not maintaining boundaries in this situation
Manipulation Scenario
Patricia Wilkes works as a correctional officer at Corcoran California state prison. Corcoran is a high security institution that houses some of the most violent male offenders. Patricia has worked at the institution for four years and has encountered two attacks against her from two separate inmates over a year span. Patricia is freshly returned back to work after being off for a week due to her injuries from her latest attack. The attack involved her being pushed down by an inmate, causing a sprain arm. Feeling vulnerable Patricia became friends with an inmate who witnessed the attack and promised to issue protection if she sneaks in contraband for him. She is conflicted but, because she is afraid; she agrees to do it.
How to Maintain Boundaries in this Situation
How to Maintain Boundaries in this Situation (continued)
How to Maintain Boundaries in this Situation (continued)
Possible Obstacles in Setting and Maintaining these Boundaries
Possible Obstacles in Setting and Maintaining these Boundaries (continued)
Possible Obstacles in Setting and Maintaining these Boundaries (continued)
Ethical and Legal Consequences to not Maintaining Boundaries in this Situation
Ethical and Legal Consequences to not Maintaining Boundaries in this Situation (continued)
Ethical and Legal Consequences to not Maintaining Boundaries in this Situation (continued)
Questions
References
HCA 4303, Comparative Health Systems 1
Course Learning Outcomes for Unit I
Upon completion of this unit, students should be able to:
1. Identify and explain how demographics, such as age and race, impact true access to quality care.
Reading Assignment
Chapter 1: Introduction
Chapter 2: Disparities in Health Care: Race and Age Matters
Unit Lesson
Many Americans find it difficult to even comprehend being denied access to medical care. When we are sick,
we want to see a physician, promptly receive a diagnosis, and procure the necessary treatment that will
restore us to our previous level of health. T ...
Infection control in healthcare facilities aims to prevent the spread of microorganisms between patients and staff. It is important as healthcare associated infections can significantly increase a patient's length of stay and risk of death. Standard precautions like hand hygiene and use of personal protective equipment are the primary methods for preventing transmission. Ongoing education of staff and monitoring adherence to policies is also key to effective infection control.
The Affordable Care Act (ACA) expands access to health insurance coverage and aims to reduce costs and improve quality of care. Key elements include establishing health insurance exchanges to help consumers find and buy plans, providing subsidies to help lower costs, and requiring insurers to cover pre-existing conditions. However, high medical costs and shortages of primary care providers remain challenges. The ACA invests in expanding community health centers to help address provider shortages.
This document summarizes a study examining Medicare payments and service use under different definitions of episodes of acute and post-acute care. The study analyzed Medicare claims data from 2008 for over 1.7 million beneficiaries with an acute hospital stay to look at episodes defined as 30, 60, or 90 days following discharge. The results provide information on healthcare utilization and costs under different episode definitions to inform policies around bundled payments. Key findings included significant geographic variation in post-acute care spending and that over one-third of beneficiaries used post-acute services after hospital discharge.
This document discusses different concepts related to purchasing healthcare and provider payment mechanisms. It begins by explaining the rationale for separating the roles of healthcare financing and provision. It then outlines various provider payment methods like fee-for-service, capitation, case-based payments, and DRGs, describing the incentives created by each. Finally, it discusses defining benefit packages to achieve universal healthcare coverage and some policy challenges for implementing these concepts in Bangladesh.
Discover Why Maxwell Hospital is the Best in Varanasi - Healthcare in VaranasiMaxwellHospital
Are you looking for top-quality healthcare in Varanasi? Look no further than Maxwell Hospital. In this video, we take a tour of the hospital and showcase its state-of-the-art facilities and equipment. From advanced diagnostic services to cutting-edge treatments, Maxwell Hospital has it all. We also introduce you to the dedicated team of doctors and nurses who work tirelessly to provide the best care possible. From general medicine to specialized care, Maxwell Hospital is committed to providing the highest level of service. Join us as we explore why this hospital is the best in Varanasi and how it's impacting the lives of the community.
https://www.maxwellhospital.in/
Overview of Patient Experience Definitions and Measurement ToolsInnovations2Solutions
This publication will provide an overview of patient experience, how it is measured, and how to achieve it optimally within the healthcare setting. Sodexo’s definition of Patient Experience will also be explored.
Understanding Healthcare Delivery Systems A Healthcare Diploma Perspective.pdfHealthcarediploma
Healthcare delivery systems are complex networks of organizations and individuals that provide healthcare services to patients. These systems involve a wide range of stakeholders, including healthcare providers, payers, government agencies, and patients themselves. Understanding healthcare delivery systems is essential for healthcare professionals who wish to improve patient outcomes and promote health equity. In this blog post, we will explore the topic of healthcare delivery systems from the perspective of a healthcare diploma student.
community health center are based on health care where Healthcare for Communities are designed to offer information on how the healthcare system is functioning in order to take care of their own health.
The document discusses several aspects of healthcare administration including the roles and responsibilities of healthcare administrators. It describes how healthcare administrators work to evaluate health problems, acquire health resources, and implement information technology systems and clinical functions to manage day-to-day operations within the healthcare industry. The goal is to improve individual wellbeing and community health by following best practices, collecting problems, providing solutions, and involving the community. Healthcare administration aims to improve processes, standards of care, and protect medical records through leadership and management.
Health Care Reform (The Affordable Care Act) .docxisaachwrensch
Health Care Reform (The Affordable Care Act)
“
ANA believes that health care is a basic human right (ANA, 1989, ANA, 1998, ANA 2005). Thus, ANA reaffirms its support for a restructured health care system that assures universal access to a standard package of essential health care services for all citizens and residents.”
“ANA believes that the development and implementation of health policies that reflect the six Institute of Medicine (IOM) aims (Safe/Effective/Patient-centered/Timely/Efficient/Equitable) and are based on outcomes research will ultimately save money.”
“The system must be reshaped and redirected away from the overuse of expensive, technology-driven, acute, hospital-based services in the model we now have, to one in which a balance is struck between high-tech treatment and community-based and preventive services, with emphasis on the latter. The solution is to invert the pyramid and focus more on primary care, thus ultimately requiring less costly secondary and tertiary care.”
Activity:
Please read the attached Health Policy Brief on Basic Health Program and “Nursing’s Role in healthcare reform” from American Nurse Today.
Please go to
www.rnaction.org
, go to the Take Action tab above to access the following information regarding health care reform and the new Affordable Care Act. Scroll down the page to the heading Resources and Supreme Court Challenge to learn more about the health care reform and how it affects you as a nurse and as an individual with a family. Check out all the different information.
HealthCare.gov
Keeping health care reform healthy, patients informed
New Animation Explains Changes Coming for Americans Under Obamacare
(7/13)
Health Care Transformation: The Affordable Care Act and How it Affects Nurses
(3/12)
Health Care Reform Legislation Timeline
ANA Policy and Provisions of Health Reform Law
National Conference of State Legislatures Health Reform Site
Kaiser Family Foundation Health Reform Page
The Supreme Court Decision Matters for Registered Nurses, their Families, and their Patients
ANA Analysis: Supreme Court Arguments on the ACA
ANA to Supreme Court: ‘Individual Mandate’ Needed to Make Health Reform Work
Then proceed to the Kaiser Foundation to watch the following:
http://kff.org
““Health Care Reform Hits Main Street on the Kaiser Foundation website or Youtube. (2010)
“New Animation Explains Changes Coming to Americans under Obamacare” (2013) Youtube or Kaiser Foundation
“
Health insurance Explained: YouToons Have it Covered”
(
2014) Youtube or Kaiser Foundation
If you would like more information regarding the ACA, the Kaiser Foundation is a great source and cover many issues.
http://kff.org
Link:
http://kff.org/health-reform/press-release/new-animation-explains-changes-coming-for-americans-under-obamacar.
The document discusses transitional care and efforts to reduce hospital readmissions. It provides background on the Hospital Readmission Penalty Program established by the Affordable Care Act and initiatives like Bundled Payments for Care Improvement (BPCI) that aim to improve care coordination. Popular tactics to reduce avoidable readmissions include patient education, risk assessment, care coordination between providers, and transitional care models.
Long-term care provides physical, psychological, social, and economic services to help people maintain or regain their optimal level of functioning. It can be delivered in various settings including at home, through hospice care, adult daycare centers, assisted living facilities, continuing care retirement communities, subacute units, and long-term care facilities. The majority of long-term care is delivered through long-term care facilities, also known as nursing homes, which provide 24-hour care for individuals who do not require hospitalization but are unable to care for themselves at home.
The document discusses bundled payments for care improvement (BPCI) initiatives created under the Patient Protection and Affordable Care Act (PPACA). It explains that PPACA aimed to move away from fee-for-service reimbursement and encourage coordinated, high-quality, lower-cost care. The Center for Medicare and Medicaid Innovation was established to test new payment models like BPCI, which link payments for multiple services during an episode of care. BPCI creates incentives to improve transitional care and reduce costs through gain-sharing arrangements between providers.
Cprn Implementing Primary Care Reform In Canadaprimary
This document discusses barriers and facilitators to implementing primary care reform in Canada. It analyzes the legacy of Canada's health policy culture, the structure and design of the healthcare system, and the supports required for policy implementation. Key barriers include the long history of focusing reform efforts on changing physician payment models and paying physicians fee-for-service. Facilitators include increasing physician willingness to consider alternative payment and the common elements of provincial reform plans, such as emphasis on multidisciplinary teams, rostering patients, and health promotion. However, implementation of primary care reform in Canada has been slow.
Leanne Wells, Chief Executive Officer, Consumers Health Forum of Australia, gave the Ian Webster Health for All Oration to the annual forum of the Centre for Primary Health Care and Equity on 13 August 2015.
Long Term Care FacilitiesLong term care facilities have gained .docxsmile790243
Long Term Care Facilities
Long term care facilities have gained popularity nowadays in the health care department. The assignment will focus two long term care facilities one facility is from nursing facility, and the other one is the adult day care. One has the responsibility of managing and administering either of the two facilities. The new managers appointed needs to be oriented and familiarized on the management of the long term care facility. The assignment provides a description of the different multidisciplinary teams, and departments included in the facilities. It also provides those who are comprised in the target population of the various programs in the care facilities. The human resource and major staffing issues faced in the home nursing and adult day care. The assignment will also focus on the significance trends likely to affect the operation of the different programs in the long term care facilities and how to overcome them. Finally, the integration and cooperation forms in the long term care facilities are outlined in the assignment. The financing, management nature and quality issues affecting cooperation and integration in the facilities are also discussed in the assignment.
Multidisciplinary teams are very essential in nursing facility. The main objective of the multidisciplinary teams is to ensure that there is improved outcome on the patients’ health status. The multidisciplinary disciplinary teams involve the staffs in the nursing facility. There are different levels of multidisciplinary teams in the nursing facilities. The levels can be grouped as follows; nurses, technicians, anesthesiologists, and attending physicians (Medicaid, 2017). The teams work together through proper communication in different levels to ensure improved outcome of the patient. The various multidisciplinary teams should be trained to work collaboratively.
The main aim of the multidisciplinary teams is to ensure that there is improved outcome on the patient’s health status. The multidisciplinary disciplinary teams involve the staffs in the adult day care. Adult day care involves taking care of an individual in all round manner. That is nutritional, health, and the daily living needs. There are different teams involved in each activity in the adult day care facility. There are nutritionist, health specialists, fitness advisor, and living advisor. For health specialists, there are different levels of multidisciplinary levels can be grouped as follows; nurses, technicians, anesthesiologists, and attending physicians (Epstein, 2014). The teams work together through proper communication in different levels to ensure improved outcome of the patient. The various multidisciplinary teams should be trained to work collaboratively. The attending doctor performs regular check up on the individuals to find out if there are any signs of disease or peculiar body behavior. After the check up, the attending physician communicates the results to the other memb ...
B Eng M Eng Rehabilitation Module 2010BevWilliams1
The document defines rehabilitation as a process that bridges the gap between medical treatment and living daily life. It aims to restore people's ability to participate in society despite disability. Rehabilitation is patient-oriented and focuses on ability rather than disease. It requires cooperation between medical and social services to address both impairment and environmental barriers.
Running Head BEHAVIORAL HEALTH SERVICES1BEHAVIORAL HEALTH .docxsusanschei
The Louisiana Medicaid program provides various behavioral health services. These include addiction services, crisis intervention, group psychotherapy, and psychosocial rehabilitation. The program also coordinates care between providers and conducts surveys to assess provider satisfaction and improve services. Sentinel events are rare medical errors that are investigated. Overall, the program aims to improve access and expand services to meet growing demand, while ensuring care is accessible to all.
What You Will Learn • The long-term care (LTC) industry consists .docxeubanksnefen
What You Will Learn • The long-term care (LTC) industry consists of various providers, insurers, LTC professionals, and an ancillary sector. • Home health care is a prime example of community-based long-term care providers. Others include homemaker and personal care service providers, adult day care providers, and hospice service providers. • Independent living and retirement centers and custodial care providers such as adult foster care facilities can be referred to as quasi-institutions. • Institutional providers range from assisted living facilities to a variety of providers that are commonly referred to as nursing homes. Some institutional long-term care services are based in hospitals. Continuing care retirement communities integrate and coordinate the independent living and other institution-based components of the LTC continuum. • Commercial insurance companies and managed care organizations play a critical role in the financing of long-term care services. • A variety of health care personnel are involved in the delivery of long-term care. • The ancillary sector supports the other segments of the industry through case management, pharmacy services, and technology. Introduction Efficient delivery of services to a nation’s population necessitates a long-term care (LTC) industry. The LTC industry mainly consists of private providers—organizations that deliver services and can independently bill for those services. In addition, some tax-supported government agencies deliver social services. This chapter elaborates on these providers as a segment of the LTC industry. Other segments of the industry include LTC professionals employed by the industry; without them the industry cannot function. They can be classified as administrative professionals, clinicians, paraprofessional caregivers, ancillary personnel, and social support professionals. In addition, key partners play vital supportive roles. These partners include the insurance industry, managed care organizations, case management agencies, long-term care pharmacies, and developers of medical technology. The Provider Sector The term provider refers to an entity that gets reimbursed for services delivered. Various private organizations and facilities, both for profit and nonprofit, are part of the LTC industry. Both LTC institutions and community-based service providers are essential to serve a variety of needs. The LTC industry is predominantly funded by the government, and certain sectors of the industry are more stringently regulated than others. Community-Based Service Providers Four main types of providers constitute the community-based sector of the LTC industry: (1) home health providers, (2) homemaker and personal care service providers, (3) adult day care providers, and (4) hospice service providers. Home Health Providers Home health care is consistent with the philosophy of maintaining people in the least restrictive environment possible. Without the availability of skille.
Senior Seminar in Business Administration BUS 499Coope.docxWilheminaRossi174
Senior Seminar in Business Administration
BUS 499
Cooperative Strategy
Hitt, M.A., Ireland, R.D., & Hoskisson, R.E. (2009). BUS499: Strategic management: Competitiveness and globalization, concepts and cases: 2009 custom edition (8th ed.). Mason, OH: South-Western Cengage Learning.
Welcome to Senior Seminar in Business Administration.
In this lesson we will discuss Cooperative Strategy.
Please go to the next slide.
ObjectivesUpon completion of this lesson, you will be able to:Identify various levels and types of strategy in a firm
Upon completion of this lesson, you will be able to:
Identify various levels and types of strategy in a firm.
Please go to the next slide.
Supporting TopicsStrategic alliancesCooperative strategiesCompetitive risks
In order to achieve this objective, the following supporting topics will be covered:
Strategic alliances;
Cooperative strategies; and
Competitive risks.
Please go to the next slide.
Strategic AlliancesCooperative strategyStrategic allianceCombination of resources and capabilitiesExchange and sharing of resourcesFirms leverage existing resourcesCornerstone of many firms’ competitive strategy
Recognized as a viable engine of firm growth, cooperative strategy is a strategy in which firms work together to achieve a shared objective. Thus, cooperating with other firms is another strategy firms use to create value for a customer that exceeds the cost of providing that value and to establish a favorable position relative to competition.
A strategic alliance is a cooperative strategy in which firms combine some of their resources and capabilities to create a competitive advantage. Thus, strategic alliances involve firms with some degree of exchange and sharing of resources and capabilities to co-develop, sell, and service goods or services. Strategic alliances allow firms to leverage their existing resources and capabilities while working with partners to develop additional resources and capabilities as the foundation for new competitive advantages. To be certain, the reality today is that strategic alliances have become a cornerstone of many firms’ competitive strategy.
Please go to the next slide.
Strategic Alliances, continuedJoint ventureEquity strategic allianceNonequity strategic alliance
The three major types of strategic alliances include joint venture, equity strategic alliance, and nonequity strategic alliance.
A joint venture is a strategic alliance in which two or more firms create a legally independent company to share some of their resources and capabilities to develop a competitive advantage. Joint ventures, which are often formed to improve firms’ abilities to compete in uncertain competitive environments, are effective in establishing long-term relationships and in transferring tacit knowledge. Because it can’t be codified, tacit, or implied, knowledge is learned through experiences such as those taking place when people from partner firms work together in a join.
Select two countries that have been or currently are in confli.docxWilheminaRossi174
Select two countries that have been or currently are in conflict.
Compare the two countries using the cultural dimensions interactive index.
Briefly describe the two countries that you selected and the conflict in which they are engaged. Explain why you selected them.
Compare the two countries on the following dimensions: collectivism-individualism, masculinity-femininity, power distance, long-term orientation, and uncertainty avoidance.
Explain what insights you had or conclusions that you might now draw about the countries and/or the conflict between them based on your comparison.
Explain the role that culture plays in this conflict and how dimensions of culture might influence the resolution of the conflict.
"Hofstede's Cultural Dimensions: Understanding Workplace Values Around the World." Notice the differences between each dimension of culture.
.
Serial KillersFor this assignment you will review a serial kille.docxWilheminaRossi174
Serial Killers
For this assignment you will review a serial killer's case in depth. The killer you choose to review will also be the subject of your Week 5 final assignment, so keep your research material handy.
First, choose
one
of the following serial killers:
David Berkowitz ("Son of Sam") taunted police over a year and shot 15 people (6 died) in New York City. The movie "Summer of Sam" was about this time.
Gary Ridgway (the "Green River Killer") holds the American record for most victims. He confessed to killing 48 over a 16-year period but is suspected of having killed many more!
Wayne B. Williams is believed to be the killer of 24 children and young men in Atlanta, though there is still some doubt.
John Allen Muhammad and Lee Boyd Malvo were the "DC snipers" who shot 13 people (ten died) over three weeks in the Washington DC area in 2002.
Ted Bundy: Confessed to almost 30 murders (there may have been more). He was known for being smart and good-looking, and acted as his own lawyer.
Jeffrey Dahmer: His case captured worldwide attention after his capture, mostly due to his habit of keeping parts of his victims long after their deaths, as well as cannibalism and necrophilia.
Kristen Gilbert: An example of a female serial killer, she was a nurse who killed hospital patients in her care.
For this assignment, create a report in Microsoft Word that covers the following points:
Summarize the case: time period, location, number of victims, etc.
Describe the killer's background, methods, and area of operation.
How did the killer select his or her victims? Was there anything that the victims did to provoke the killer?
By analyzing all of the above information, you should now be able to propose a
three-part typology
and explain your analysis. Your typology should describe the killer's
motivation, location, and organized or disorganized factors. For instance, John Wayne Gacy might be described as a
Power/Control, local, organized killer.
.
SESSION 1Michael Delarosa, Department ManagerWhat sugg.docxWilheminaRossi174
SESSION 1
Michael Delarosa, Department Manager
What suggestions do you have for improvement in regards to training new supervisors?
Make sure there are opportunities for hands on problem solving. Too much of our training is theory
and supervisors need to be focused on the real-world problems that come up.
What challenges do supervisors in our plants encounter that training would help them resolve?
I'd say that a lot of the challenges we see relate to the diversity on the line. There are a lot of different
types of people working at CapraTek and they don't always play well together.
What are the most important abilities for supervisors in our plants?
Well… the first thing that comes to mind is the ability to find information. Whether it's technical
information or answers for the people who report to you. Another key ability though is the ability to
acquire technical expertise. No one comes in knowing it all, but the ability to gain necessary
knowledge is very important.
What knowledge does a new supervisor need?
A solid understanding of the job itself. Supervisors provide a lot of training to new employees, so they
need to know our systems and processes inside and out.
Should training be conducted face to face, online, or a combination of both?
I'd say a combination. There are some topics that don't really need a classroom experience, but
others where the face-to-face interaction provides as much as the actual training materials. If it had to
be one or the other, I'd definitely say face to face.
Leland Butler, Shift Supervisor
What suggestions do you have for improvement in regards to training new supervisors?
Don't think you can cover this stuff once and be done with it. I went through supervisor training when I
was promoted, but I've gotta admit, I don't remember much of it. That kind of stuff doesn't always
stick unless you're doing it. Having an opportunity to be in the job and then get training on what you're
actually dealing with is better than sitting in a training room listening to someone talk about theories
and policies.
What challenges do supervisors in our plants encounter that training would help them resolve?
Well… like I said, being able to apply the leadership and supervisory ideas in realistic situations. I'm a
hands-on kind of person and it's always better if I can do something, so maybe like getting training on
performance reviews or some of the paperwork we're all dealing with. That would be helpful.
What are the most important abilities for supervisors in our plants?
Communication and flexibility. Hands down. You need to be able to shift gears decisively and
communicate with your team.
What knowledge does a new supervisor need?
He or she needs to know what the role of their team is to the division. How it all fits together. A good
supervisor needs to be able to communicate to the people who report to him what's going on and why
things are the way they are. So, he's got to be in .
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Health Care Reform (The Affordable Care Act) .docxisaachwrensch
Health Care Reform (The Affordable Care Act)
“
ANA believes that health care is a basic human right (ANA, 1989, ANA, 1998, ANA 2005). Thus, ANA reaffirms its support for a restructured health care system that assures universal access to a standard package of essential health care services for all citizens and residents.”
“ANA believes that the development and implementation of health policies that reflect the six Institute of Medicine (IOM) aims (Safe/Effective/Patient-centered/Timely/Efficient/Equitable) and are based on outcomes research will ultimately save money.”
“The system must be reshaped and redirected away from the overuse of expensive, technology-driven, acute, hospital-based services in the model we now have, to one in which a balance is struck between high-tech treatment and community-based and preventive services, with emphasis on the latter. The solution is to invert the pyramid and focus more on primary care, thus ultimately requiring less costly secondary and tertiary care.”
Activity:
Please read the attached Health Policy Brief on Basic Health Program and “Nursing’s Role in healthcare reform” from American Nurse Today.
Please go to
www.rnaction.org
, go to the Take Action tab above to access the following information regarding health care reform and the new Affordable Care Act. Scroll down the page to the heading Resources and Supreme Court Challenge to learn more about the health care reform and how it affects you as a nurse and as an individual with a family. Check out all the different information.
HealthCare.gov
Keeping health care reform healthy, patients informed
New Animation Explains Changes Coming for Americans Under Obamacare
(7/13)
Health Care Transformation: The Affordable Care Act and How it Affects Nurses
(3/12)
Health Care Reform Legislation Timeline
ANA Policy and Provisions of Health Reform Law
National Conference of State Legislatures Health Reform Site
Kaiser Family Foundation Health Reform Page
The Supreme Court Decision Matters for Registered Nurses, their Families, and their Patients
ANA Analysis: Supreme Court Arguments on the ACA
ANA to Supreme Court: ‘Individual Mandate’ Needed to Make Health Reform Work
Then proceed to the Kaiser Foundation to watch the following:
http://kff.org
““Health Care Reform Hits Main Street on the Kaiser Foundation website or Youtube. (2010)
“New Animation Explains Changes Coming to Americans under Obamacare” (2013) Youtube or Kaiser Foundation
“
Health insurance Explained: YouToons Have it Covered”
(
2014) Youtube or Kaiser Foundation
If you would like more information regarding the ACA, the Kaiser Foundation is a great source and cover many issues.
http://kff.org
Link:
http://kff.org/health-reform/press-release/new-animation-explains-changes-coming-for-americans-under-obamacar.
The document discusses transitional care and efforts to reduce hospital readmissions. It provides background on the Hospital Readmission Penalty Program established by the Affordable Care Act and initiatives like Bundled Payments for Care Improvement (BPCI) that aim to improve care coordination. Popular tactics to reduce avoidable readmissions include patient education, risk assessment, care coordination between providers, and transitional care models.
Long-term care provides physical, psychological, social, and economic services to help people maintain or regain their optimal level of functioning. It can be delivered in various settings including at home, through hospice care, adult daycare centers, assisted living facilities, continuing care retirement communities, subacute units, and long-term care facilities. The majority of long-term care is delivered through long-term care facilities, also known as nursing homes, which provide 24-hour care for individuals who do not require hospitalization but are unable to care for themselves at home.
The document discusses bundled payments for care improvement (BPCI) initiatives created under the Patient Protection and Affordable Care Act (PPACA). It explains that PPACA aimed to move away from fee-for-service reimbursement and encourage coordinated, high-quality, lower-cost care. The Center for Medicare and Medicaid Innovation was established to test new payment models like BPCI, which link payments for multiple services during an episode of care. BPCI creates incentives to improve transitional care and reduce costs through gain-sharing arrangements between providers.
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Leanne Wells, Chief Executive Officer, Consumers Health Forum of Australia, gave the Ian Webster Health for All Oration to the annual forum of the Centre for Primary Health Care and Equity on 13 August 2015.
Long Term Care FacilitiesLong term care facilities have gained .docxsmile790243
Long Term Care Facilities
Long term care facilities have gained popularity nowadays in the health care department. The assignment will focus two long term care facilities one facility is from nursing facility, and the other one is the adult day care. One has the responsibility of managing and administering either of the two facilities. The new managers appointed needs to be oriented and familiarized on the management of the long term care facility. The assignment provides a description of the different multidisciplinary teams, and departments included in the facilities. It also provides those who are comprised in the target population of the various programs in the care facilities. The human resource and major staffing issues faced in the home nursing and adult day care. The assignment will also focus on the significance trends likely to affect the operation of the different programs in the long term care facilities and how to overcome them. Finally, the integration and cooperation forms in the long term care facilities are outlined in the assignment. The financing, management nature and quality issues affecting cooperation and integration in the facilities are also discussed in the assignment.
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The main aim of the multidisciplinary teams is to ensure that there is improved outcome on the patient’s health status. The multidisciplinary disciplinary teams involve the staffs in the adult day care. Adult day care involves taking care of an individual in all round manner. That is nutritional, health, and the daily living needs. There are different teams involved in each activity in the adult day care facility. There are nutritionist, health specialists, fitness advisor, and living advisor. For health specialists, there are different levels of multidisciplinary levels can be grouped as follows; nurses, technicians, anesthesiologists, and attending physicians (Epstein, 2014). The teams work together through proper communication in different levels to ensure improved outcome of the patient. The various multidisciplinary teams should be trained to work collaboratively. The attending doctor performs regular check up on the individuals to find out if there are any signs of disease or peculiar body behavior. After the check up, the attending physician communicates the results to the other memb ...
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What You Will Learn • The long-term care (LTC) industry consists of various providers, insurers, LTC professionals, and an ancillary sector. • Home health care is a prime example of community-based long-term care providers. Others include homemaker and personal care service providers, adult day care providers, and hospice service providers. • Independent living and retirement centers and custodial care providers such as adult foster care facilities can be referred to as quasi-institutions. • Institutional providers range from assisted living facilities to a variety of providers that are commonly referred to as nursing homes. Some institutional long-term care services are based in hospitals. Continuing care retirement communities integrate and coordinate the independent living and other institution-based components of the LTC continuum. • Commercial insurance companies and managed care organizations play a critical role in the financing of long-term care services. • A variety of health care personnel are involved in the delivery of long-term care. • The ancillary sector supports the other segments of the industry through case management, pharmacy services, and technology. Introduction Efficient delivery of services to a nation’s population necessitates a long-term care (LTC) industry. The LTC industry mainly consists of private providers—organizations that deliver services and can independently bill for those services. In addition, some tax-supported government agencies deliver social services. This chapter elaborates on these providers as a segment of the LTC industry. Other segments of the industry include LTC professionals employed by the industry; without them the industry cannot function. They can be classified as administrative professionals, clinicians, paraprofessional caregivers, ancillary personnel, and social support professionals. In addition, key partners play vital supportive roles. These partners include the insurance industry, managed care organizations, case management agencies, long-term care pharmacies, and developers of medical technology. The Provider Sector The term provider refers to an entity that gets reimbursed for services delivered. Various private organizations and facilities, both for profit and nonprofit, are part of the LTC industry. Both LTC institutions and community-based service providers are essential to serve a variety of needs. The LTC industry is predominantly funded by the government, and certain sectors of the industry are more stringently regulated than others. Community-Based Service Providers Four main types of providers constitute the community-based sector of the LTC industry: (1) home health providers, (2) homemaker and personal care service providers, (3) adult day care providers, and (4) hospice service providers. Home Health Providers Home health care is consistent with the philosophy of maintaining people in the least restrictive environment possible. Without the availability of skille.
Similar to Chapter 5Subacute andPostacute CareLearning Object (18)
Senior Seminar in Business Administration BUS 499Coope.docxWilheminaRossi174
Senior Seminar in Business Administration
BUS 499
Cooperative Strategy
Hitt, M.A., Ireland, R.D., & Hoskisson, R.E. (2009). BUS499: Strategic management: Competitiveness and globalization, concepts and cases: 2009 custom edition (8th ed.). Mason, OH: South-Western Cengage Learning.
Welcome to Senior Seminar in Business Administration.
In this lesson we will discuss Cooperative Strategy.
Please go to the next slide.
ObjectivesUpon completion of this lesson, you will be able to:Identify various levels and types of strategy in a firm
Upon completion of this lesson, you will be able to:
Identify various levels and types of strategy in a firm.
Please go to the next slide.
Supporting TopicsStrategic alliancesCooperative strategiesCompetitive risks
In order to achieve this objective, the following supporting topics will be covered:
Strategic alliances;
Cooperative strategies; and
Competitive risks.
Please go to the next slide.
Strategic AlliancesCooperative strategyStrategic allianceCombination of resources and capabilitiesExchange and sharing of resourcesFirms leverage existing resourcesCornerstone of many firms’ competitive strategy
Recognized as a viable engine of firm growth, cooperative strategy is a strategy in which firms work together to achieve a shared objective. Thus, cooperating with other firms is another strategy firms use to create value for a customer that exceeds the cost of providing that value and to establish a favorable position relative to competition.
A strategic alliance is a cooperative strategy in which firms combine some of their resources and capabilities to create a competitive advantage. Thus, strategic alliances involve firms with some degree of exchange and sharing of resources and capabilities to co-develop, sell, and service goods or services. Strategic alliances allow firms to leverage their existing resources and capabilities while working with partners to develop additional resources and capabilities as the foundation for new competitive advantages. To be certain, the reality today is that strategic alliances have become a cornerstone of many firms’ competitive strategy.
Please go to the next slide.
Strategic Alliances, continuedJoint ventureEquity strategic allianceNonequity strategic alliance
The three major types of strategic alliances include joint venture, equity strategic alliance, and nonequity strategic alliance.
A joint venture is a strategic alliance in which two or more firms create a legally independent company to share some of their resources and capabilities to develop a competitive advantage. Joint ventures, which are often formed to improve firms’ abilities to compete in uncertain competitive environments, are effective in establishing long-term relationships and in transferring tacit knowledge. Because it can’t be codified, tacit, or implied, knowledge is learned through experiences such as those taking place when people from partner firms work together in a join.
Select two countries that have been or currently are in confli.docxWilheminaRossi174
Select two countries that have been or currently are in conflict.
Compare the two countries using the cultural dimensions interactive index.
Briefly describe the two countries that you selected and the conflict in which they are engaged. Explain why you selected them.
Compare the two countries on the following dimensions: collectivism-individualism, masculinity-femininity, power distance, long-term orientation, and uncertainty avoidance.
Explain what insights you had or conclusions that you might now draw about the countries and/or the conflict between them based on your comparison.
Explain the role that culture plays in this conflict and how dimensions of culture might influence the resolution of the conflict.
"Hofstede's Cultural Dimensions: Understanding Workplace Values Around the World." Notice the differences between each dimension of culture.
.
Serial KillersFor this assignment you will review a serial kille.docxWilheminaRossi174
Serial Killers
For this assignment you will review a serial killer's case in depth. The killer you choose to review will also be the subject of your Week 5 final assignment, so keep your research material handy.
First, choose
one
of the following serial killers:
David Berkowitz ("Son of Sam") taunted police over a year and shot 15 people (6 died) in New York City. The movie "Summer of Sam" was about this time.
Gary Ridgway (the "Green River Killer") holds the American record for most victims. He confessed to killing 48 over a 16-year period but is suspected of having killed many more!
Wayne B. Williams is believed to be the killer of 24 children and young men in Atlanta, though there is still some doubt.
John Allen Muhammad and Lee Boyd Malvo were the "DC snipers" who shot 13 people (ten died) over three weeks in the Washington DC area in 2002.
Ted Bundy: Confessed to almost 30 murders (there may have been more). He was known for being smart and good-looking, and acted as his own lawyer.
Jeffrey Dahmer: His case captured worldwide attention after his capture, mostly due to his habit of keeping parts of his victims long after their deaths, as well as cannibalism and necrophilia.
Kristen Gilbert: An example of a female serial killer, she was a nurse who killed hospital patients in her care.
For this assignment, create a report in Microsoft Word that covers the following points:
Summarize the case: time period, location, number of victims, etc.
Describe the killer's background, methods, and area of operation.
How did the killer select his or her victims? Was there anything that the victims did to provoke the killer?
By analyzing all of the above information, you should now be able to propose a
three-part typology
and explain your analysis. Your typology should describe the killer's
motivation, location, and organized or disorganized factors. For instance, John Wayne Gacy might be described as a
Power/Control, local, organized killer.
.
SESSION 1Michael Delarosa, Department ManagerWhat sugg.docxWilheminaRossi174
SESSION 1
Michael Delarosa, Department Manager
What suggestions do you have for improvement in regards to training new supervisors?
Make sure there are opportunities for hands on problem solving. Too much of our training is theory
and supervisors need to be focused on the real-world problems that come up.
What challenges do supervisors in our plants encounter that training would help them resolve?
I'd say that a lot of the challenges we see relate to the diversity on the line. There are a lot of different
types of people working at CapraTek and they don't always play well together.
What are the most important abilities for supervisors in our plants?
Well… the first thing that comes to mind is the ability to find information. Whether it's technical
information or answers for the people who report to you. Another key ability though is the ability to
acquire technical expertise. No one comes in knowing it all, but the ability to gain necessary
knowledge is very important.
What knowledge does a new supervisor need?
A solid understanding of the job itself. Supervisors provide a lot of training to new employees, so they
need to know our systems and processes inside and out.
Should training be conducted face to face, online, or a combination of both?
I'd say a combination. There are some topics that don't really need a classroom experience, but
others where the face-to-face interaction provides as much as the actual training materials. If it had to
be one or the other, I'd definitely say face to face.
Leland Butler, Shift Supervisor
What suggestions do you have for improvement in regards to training new supervisors?
Don't think you can cover this stuff once and be done with it. I went through supervisor training when I
was promoted, but I've gotta admit, I don't remember much of it. That kind of stuff doesn't always
stick unless you're doing it. Having an opportunity to be in the job and then get training on what you're
actually dealing with is better than sitting in a training room listening to someone talk about theories
and policies.
What challenges do supervisors in our plants encounter that training would help them resolve?
Well… like I said, being able to apply the leadership and supervisory ideas in realistic situations. I'm a
hands-on kind of person and it's always better if I can do something, so maybe like getting training on
performance reviews or some of the paperwork we're all dealing with. That would be helpful.
What are the most important abilities for supervisors in our plants?
Communication and flexibility. Hands down. You need to be able to shift gears decisively and
communicate with your team.
What knowledge does a new supervisor need?
He or she needs to know what the role of their team is to the division. How it all fits together. A good
supervisor needs to be able to communicate to the people who report to him what's going on and why
things are the way they are. So, he's got to be in .
Selecting & Implementing Interventions – Assignment #4
image1.png
image2.png
image3.png
Behavioral Interventions
Behav. Intervent. 19: 205–228 (2004)
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/bin.161
MODIFICATIONS TOBASIC FUNCTIONAL
ANALYSIS PROCEDURES IN SCHOOL
SETTINGS: A SELECTIVE REVIEW
Janet Ellis* and Sandy Magee
University of North Texas, Denton, TX, USA
This review describes applied behavioral research involving functional analyses conducted in public
school settings. Functional analyses in public school settings often require added conditions. The
modified conditions described herein include changes to experimental designs, antecedent changes that
include task variation, tasks included, idiosyncratic variables, physiological conditions, and modified
escape conditions. Finally, consequent modifications cover peer attention, tangibles, varied attention,
and altered escape. Copyright # 2004 John Wiley & Sons, Ltd.
INTRODUCTION
The primary body of functional analysis (FA) literature has historically focused on
persons with developmental disabilities in institutional/residential settings who
engaged in severe self-injurious behavior (SIB). Mace and Lalli (1991) noted that
interventions based on FAs conducted in experimental settings under highly
controlled analog conditions may be effective only to the extent that those analog
conditions match the subject’s natural environment. Johnston (1993) recommended
that, once a procedure has been experimentally developed, its value and applicability
should be assessed under practical/natural conditions. Further, passage of Public Law
105-17, Individuals with Disabilities Education Act (IDEA), in 1997 mandated that a
‘functional behavioral assessment’ be conducted on students who exhibit significant
behavior and adjustment problems. For at least these reasons, FA research has moved
beyond the tightly controlled laboratory setting and into more natural environments
involving more diverse populations. Development of behavioral assessments of
problem behavior in school settings had empirical roots—for example, 36 years ago
Thomas, Becker, and Armstrong (1968) noted that classroom teacher’s disapproval
increased rates of student’s disruptive behavior. These assessments allowed effective
Copyright # 2004 John Wiley & Sons, Ltd.
*Correspondence to: Janet Ellis, Department of Behavior Analysis, University of North Texas, P.O. Box 310919,
Denton, TX 76203-0919, USA. E-mail: [email protected]
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See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/299831446
A Case Study of Global Leadership Development
Best Practice
Article · April 2016
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A Case Study of Global
Leadership Development
Best Practice
“GLD is a challenging task that has become more imp.
Shared Reading FrameworkFollow this framework when viewing the v.docxWilheminaRossi174
Shared Reading Framework
Follow this framework when viewing the video lessons for Days 1,2, & 3 from Ms. Chan’s class. Compare and contrast Ms. Chan’s teaching to what is listed on this page.
(Whole)
Read aloud a shared or big book to the students. Label each step and clearly state how you will accomplish this.
·
Introduce the book: Explain what you will say to the students to introduce the book to them, if you choose to point out concepts of book, concepts of print, predicting, etc.
·
Picture Walk: Explain what you will do to provide a Picture Walk for the students, telling all that you will say to the students.
·
Read the book aloud: Explain how you will read the book aloud to the students, will you stop, on what pages, what will you say.
·
Students’ Responses: Develop a set of both literal and higher-order thinking questions to elicit student responses, use Bloom’s or Webb’s as a guide to questions.
(PART)
Direct Instruction (Name the reading skill and explain what it means)
· Explain:
(I do) Explain to the students what they will be learning and why they should learn it. Explain the skill they will be learning and explain “how it works” Summarize the skill in your own words. Teacher tells students everything you want them to learn
(objectives).
· Demonstrate
: (I do) Show the students what you would like them to do. Demonstrate to them what they will be doing to help them learn the skill. You must explain what you will do to demonstrate the skill you will be teaching. PROVIDE EXAMPLES and link to your explain step.
· Guide:
(We do, more teacher responsibility, some student responsibility) Guide the students to discuss and/or attempt the skill you just demonstrated. Explain how you will guide the students to allow them opportunities to try to apply the skill. Give support and feedback. Teacher brings students into discussion about objective and gives guidance and feedback
. (Feedback must be accurate, positive and encouraging, but also firm.)
· Practice:
(We do, more student responsibility) Explain specifically how you will guide the students to practice applying the skill by allowing them to work together with less teacher support but still feedback.
(WHOLE)
· Application:
(You do) (Read the book again and this time ask the students to apply what they learned about the reading skill to the book you are rereading.) Explain what you will have the students do to apply the skill to the text. The students should demonstrate that they can meet objective in this step.
· Students Reflect:
(You do) Develop a set of 6 – 8 questions you would ask the students to reflect on what they learned about the reading skill and what they learned from the book you read to them. This is a good time to ask questions that would meet.
Self-disclosureDepth of reflectionResponse demonstrates an in.docxWilheminaRossi174
Self-disclosure/Depth of reflection
Response demonstrates an in-depth reflection on, and personalization of, the theories, concepts, and/or strategies presented in the course materials to date. Viewpoints and interpretations are insightful and well supported. Clear, detailed examples are provided, as applicable. Demonstrates an open, non-defensive ability to self-appraise, discussing both growth and frustrations as they related to learning in class, as well as implications for future learning.
Analysis/Connection to reading and outside experiences
In-depth synthesis of thoughtfully selected aspects of experiences related to the course topics. Makes clear connections between what is learned from readings, outside experiences and the topics. The reflection is an in-depth analysis of the learning experience, the value of the derived learning to self or others, and the enhancement of the student’s appreciation for the discipline. Demonstrate further analysis and insight resulting from what you have learned from readings, includes reference to at least two readings other than those assigned for class.
Connection to course objectives and BSN outcomes
Synthesize, analyze and evaluate thoughtfully selected aspects of ideas or issues from the class discussion as they relate to the course learning outcomes and the BSN program outcome. (Review your syllabus and students handbook to help make connections)
Structure, organization and grammar
Writing is clear, concise, and well organized with excellent sentence/paragraph construction. Thoughts are expressed in a coherent and logical manner. There are no more than three spelling, grammar, or syntax errors per page of writing.
APA format, page limitations and spelling
Follows APA professional writing style of using 12 point Times New Roman
font, 1inch margins all around, correct
APA headings, and correct format of title page.
.
Seemingly riding on the coattails of SARS-CoV-2, the alarming sp.docxWilheminaRossi174
Seemingly riding on the coattails of SARS-CoV-2, the alarming spread of monkeypox across western Europe and the United States has filled the news cycle through the summer of 2022. Monkeypox is an orthopoxvirus, similar in presentation to smallpox and chickenpox (Varicella zoster). In contrast to the related poxviruses, monkeypox has been reported to spread by sexual contact and direct skin-to-skin contact, as well as through the traditional respiratory droplet route. While there is currently no effective treatment for infected individuals, two vaccines with good efficacy are available to help stem the spread of the disease. Likewise, individuals that have been vaccinated against smallpox with vaccinia virus have some protection against contracting monkeypox. While changes in sexual behavior among vulnerable populations has so far limited the outbreak, the disease is still spreading throughout the country and has caused a handful of deaths.
What is the life cycle of monkeypox, and how exactly is it spread? What does the fact that vaccination against smallpox provides some protection against monkeypox indicate about this virus? Also, what does the spread of monkeypox reveal about the susceptibility of the population to smallpox, a disease that has been considered eradicated worldwide since the late 1980s?
In addition to your original response, you will need to respond to at least two other students’ original posts. Responses should be substantive in nature instead of just reiterating what the original poster stated, or a “good job explaining” or “me too” type of post.
Please note that in your response, plagiarism is not allowed. Please do NOT simply cut and paste information from books, journals, websites, or other sources. In addition, direct quotation of sources, regardless of whether or not the source is cited, is not allowed. Please summarize the material and what you have learned in your own words.
.
See the attachment of 1 Article belowPlease answer all the que.docxWilheminaRossi174
See the attachment of 1 Article below
Please answer all the questions below in 1-2 pages (in MLA)
1) the important concepts and terms of the readings
2) the most important arguments of the readings
3) the parts of the readings they found confusing or unclear
4) how this reading relates to previous class readings, lectures, and discussions
You do not need to have a work cited page unless you have outside materials. Please let me know if you have questions.
.
SHAPING SCHOOL CULTURE BY LIVING THE VISION AND MISSIONNameI.docxWilheminaRossi174
SHAPING SCHOOL CULTURE BY LIVING THE VISION AND MISSION
Name
Institution
Date
School
Hello everyone and welcome to today’s presentation. The school in focus is Highland High School which has 9 to 12th grade.
2
Name
Highland High School
Grade levels
9 to 12
Mission
The mssion of the school is to “Empower students to use knowledge, skills, and strategies to become productive members of society who use higher level thinking”. The vision of the school is Students will “Own Their learning”
3
Mission statement
“Empower students to use knowledge, skills, and strategies to become productive members of society who use higher level thinking”
Vision statement
Students will “Own Their learning”
Strategies that embed the mission and vision
It is possible for a school to convey its ethos, mission, goals, and values to its students, staff, and parents in a variety of different methods. A school's prospectus or handbook should present information in a way that is clear and easy to comprehend, taking into account the diverse ethnic group in the area and maybe translating the text into many languages. The website of the school is the spot that makes the most sense to transmit any sort of information regarding the institution as a whole, including its ethos and so on. The internet is the first place that people search for information in this day and age since it can be accessed from anywhere in the world and every school now has its own personal website. Again, in order to experience the true environment of the school, it is necessary to combine this mode of communication with a trip to the location itself.
4
Strategy 1
Communication
Repetitive communication of the mission and vision ensures it is embedded (Jensen et al., 2018)
Communications will target all stakeholders
Technology tools will be used to facilitate communication to all stakeholders
Strategies that embed the mission and vision cont…
A well-defined statement that provides an explanation of the line of work that an individual plans to pursue over the entirety of his career is an example of a career objective. It is essential for each and every student to articulate their aspirations for their future careers. They are able to devise more efficient action plans as a result of this.
5
Strategy 2
Helping students establish career goals
Students will be encouraged to work hard to actualize the goals
Successful careers enable students to become productive members of the society (Şenol & Lesinger, 2018)
Strategies that embed the mission and vision cont…
Finding and employing the appropriate faculty members is possibly the single most significant factor that will determine the institution's long-term success. Even though conducting interviews and making hires is seen by many as an art form, there are tried-and-true strategies that the school may employ to boost its chances of finding the proper people to work there. These approaches are suppo.
Select a healthcare legislature of interest. Discuss the historica.docxWilheminaRossi174
Select a healthcare legislature of interest. Discuss the historical background of the legislation. For example, the person(s) who presented the bill. The committees the bill went through, and revision of the bill until it was passed into law. For example, health insurance is a problem within the USA. The ACA bill was created and pass into law.
.
See discussions, stats, and author profiles for this publicati.docxWilheminaRossi174
See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/13998136
Self-management within a token economy for students with
learning disabilities
Article in Research in Developmental Disabilities · May 1997
DOI: 10.1016/S0891-4222(96)00045-5 · Source: PubMed
CITATIONS
17
READS
1,084
3 authors, including:
Some of the authors of this publication are also working on these related projects:
Self-regulation View project
Animal Assisted Physical Activity View project
Al Cavalier
University of Delaware
29 PUBLICATIONS 491 CITATIONS
SEE PROFILE
Ralph P Ferretti
University of Delaware
46 PUBLICATIONS 1,276 CITATIONS
SEE PROFILE
All content following this page was uploaded by Al Cavalier on 30 June 2018.
The user has requested enhancement of the downloaded file.
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Segmented Assimilation Theory and theLife Model An Integrat.docxWilheminaRossi174
Segmented Assimilation Theory and the
Life Model: An Integrated Approach to
Understanding Immigrants and Their Children
Lissette M. Piedra and David W Engstrom
The life model offers social workers a promising framework to use in assisting immigrant
families. However, the complexities of adaptation to a new country may make it difficult
for social workers to operate from a purely ecological approach. The authors use segmented
assimilation theory to better account for the specificities of the immigrant experience. They
argue that by adding concepts from segmented assimilation theory to the life model, social
workers can better understand the environmental Stressors that increase the vulnerabilities
of immigrants to the potentially harsh experience of adapting to a new country. With these
concepts, social workers who work with immigrant families will be better positioned to
achieve their central goal: enhancing person and environment fit.
KEY WORDS: acculturation; assimilation; immigrants; life model; second generation
Nearly a century ago,Jane Addams (1910)
observed that immigrants needed help
integrating their European and American
experiences to give them meaning and a sense of
relation:
Power to see life as a whole is more needed in
the immigrant quarter of the city than anywhere
else Why should the chasm between fathers
and sons, yawning at the feet of each generation,
be made so unnecessarily cruel and impassable
to these bewildered immigrants? (p. 172)
The inability of some immigrant families to
integrate the cultural capital from the world left
behind with the demands of the new society creates
a gulf of experience between immigrants and their
children that can undermine the parental relation-
ship. Today, the issue of family cohesion in the face
of acculturative Stressors remains central to the im-
migrant experience and creates a sense of urgency
because it is so linked with the success of the second
generation. The size of the immigrant population
and the role their children \vill play in future labor
markets (Morales & Bonilla, 1993; Sullivan, 2006)
moves the problem from the realm of the person
to the status of a larger public concern.
Immigrant families are rapidly becoming the
"typical" American family. More than one in seven
families in the United States is headed by a foreign-
born adult. Children of immigrant parents are the
fastest growing segment of the nation's child popula-
tion (Capps, Fix, Ost, Reardon-Anderson, & Passel,
2004).The U.S. Census Bureau (2003) reported that
slightly more than 14 million children (approxi-
mately one in five) live in immigrant families; the
percentage is even higher (22 percent) for children
under the age of six (U.S. Census Bureau, 2001).
At a structural level, these changing demographics
create large-scale and long-range effects that bear
on many social services and many issues of social
pohcy (Sullivan, 2006). Specifically, the population
growth of native-born children in nonwhite.
Select a local, state, or national public policy that is relev.docxWilheminaRossi174
Select a local, state, or national public policy that is relevant today in the local, regional, or national news
Examples:
Local: community or urban growth (examples: results of rezoning, reuse of public structures, closed down school/public buildings that will convert to private business enterprise).
State: Private land converted to public spaces (examples: airports, road, or highway usage).
Federal: Gun policy, drug policy, immigration (examples: effects on jobs, background checks, cultural changes in communities).
Identify how the policy was formulated from a historical standpoint and identify which stakeholders were involved in the process.
Appraise the position whether the policy creates a benefit for one group (or stakeholder) while other groups experience disadvantages or negative challenges because of public policy implementation.
.
School of Community and Environmental HealthMPH Program .docxWilheminaRossi174
School of Community and Environmental Health
MPH Program
Epidemiology: MPH 746
(
Second
Assignment
)
(
Type in you name here as
First Name , Last Name
)
Read the Paper below and answer the following questions. Your answer should be typed in below; and the submitted document should be in Microsoft Word document. The answer for any question should not exceed one paragraph (5-6 lines). The deadline for submission is 11:59 pm EST Nov. 9th, 2022.
(
Ellison LF, Morrison HI:
Low serum cholesterol concentration and risk of suicide
.
Epidemiology
2001,
12
(2):168-172.
)
Question1 (Max. 0.5 point)
What is the purpose of the study?
Question2 (Max. 0.5 point)
What is the study design? What is the exposure? What is the outcome?
Question3 (Max. 2 points)
How the exposure was measured? How the outcome was measured?
Question4 (Max. 1.5 points)
From Table II, calculate the Crude Rate Ratio for serum total cholesterol <4.27 mmol/l compared to >5.77 mmol/l. (must show the details of calculation)
Question5 (Max. 1.5 points)
What is the meaning of this crude Rate Ratio?
Question6 (Max. 1.5 points)
In Table 3, what is the meaning of age and sex adjusted RR of serum total cholesterol <4.27 mmol/l compared to serum total cholesterol >5.77 mmol/l. Was there confounding by age and sex, why or why not? Is the RR statistically significant? What is the meaning of the 95%CI for the RR?
Question7 (Max. 0.5 points)
Was the ascertainment of the outcome as complete as possible? Was there a follow chart?
Question8 (Max. 0.5 points)
The authors stated in the discussion “The possibility of under-ascertainment of suicide deaths is always a concern, although it is probably unlikely that ascertainment varied by serum total cholesterol level”
Explain what the authors meant by their statement.
Question9 (Max. 0.5 points)
Were those who measured the outcome blinded from the exposure status?
Question10 (Max. 0.5 points)
Have the exposures been well measured, or is there any random or systematic misclassification?
Question11 (Max. 5 points)
Do the “exposed” differ from the “unexposed” with respect to other factors? Have these differences taken into account in the design or analysis? i.e. How the authors dealt with confounding?
1
image1.png
Students will synthesize the information they have gathered during the course to formulate a presentation advocating for a practice change in relation to an area of interest to NP practice.
Creating a Professional PowerPoint PresentationDownload Creating a Professional PowerPoint Presentation
In a PowerPoint Presentation, address the following.
1.
Title Slide
2.
Introduction (1 slide): Slide should identify concepts to be addressed and sections of the presentation. Include speaker’s notes that explain, in more detail, what will be covered.
.
School Effects on Psychological Outcomes During Adolescence.docxWilheminaRossi174
School Effects on Psychological Outcomes During Adolescence
Eric M. Anderman
University of Kentucky
Data from the National Longitudinal Study of Adolescent Health were used to examine school-level
differences in the relations between school belonging and various outcomes. In Study 1, predictors of
belonging were examined. Results indicated that belonging was lower in urban schools than in suburban
schools, and lower in schools that used busing practices than those that did not. In Study 2, the relations
between belonging and psychological outcomes were examined. The relations varied depending on the
unit of analysis (individual vs. aggregated measures of belonging). Whereas individual students’
perceptions of belonging were inversely related to depression, social rejection, and school problems,
aggregated belonging was related to greater reports of social rejection and school problems and to higher
grade point average.
Research on school-level differences during adolescence often
has focused on nonpsychological outcomes, such as academic
achievement and behavioral issues, instead of on psychological
outcomes (Roeser, 1998). Indeed, research on school-level differ-
ences in nonacademic variables is quite rare. The purpose of the
present research was to examine school-level differences in a
variety of psychological outcomes, using a large nationally repre-
sentative sample of adolescents.
School Effects on Student Outcomes
Although there is an abundant literature on effective schools,
most of the research in this literature has focused on academic
variables, such as achievement, dropping out, and grade point
average (GPA; e.g., Edmonds, 1979; Miller, 1985; Murphy, Weil,
Hallinger, & Mitman, 1985). This literature generally indicates
that schools that are academically effective have certain recogniz-
able characteristics.
Some of these studies have examined differences between pub-
lic schools and other types of schools. For example, some research
indicates that students who attend public schools achieve more
academically than do students who attend other types of schools
(e.g., Coleman & Hoffer, 1987). Other research suggests that there
may be a benefit in terms of academic achievement for students
who attend Catholic schools compared with non-Catholic schools
(Bryk, Lee, & Holland, 1993). Lee and her colleagues (Lee,
Chow-Hoy, Burkam, Geverdt, & Smerdon, 1998) found that stu-
dents who attended private schools took more advanced math
courses than did students who attended public schools. However,
they also found specific benefits for Catholic schools: Specifically,
in Catholic schools, there was greater school influence on the
courses that students took, and the social distribution of course
enrollment was found to be particularly equitable.
In recent years, psychologists have started to become interested
in the effects of schooling on mental health outcomes (e.g., Boe-
kaerts, 1993; Cowen, 1991; Roeser, Eccles, & Strobel, 1998;
Rutter,.
Search the gene belonging to the accession id you selected in week 2.docxWilheminaRossi174
Search the gene belonging to the accession id you selected in week 2. Use both Ensembl
https://useast.ensembl.org/index.html
and UCSC
https://genome.ucsc.edu/cgi-bin/hgGateway
genomic browsers to get these genomic/sequence features.
For transcript information including UTRs. provide:
Chromosome
Gene location
Coordinates (exons and introns) these are positions in the sequence
Total exon count -> state if this was the same as what you retrieved from NCBI. Note it could be different because it is a different organism.
ORF Strand: some tools present with signs such as -/+, others will state positive/negative or forward/reverse
promoter region
Coding Region
Coordinates (start and end sequence positions)
coding exon count (this may differ from the total count).
positions for coding exons
Compare and contrast the level of information provided by the two genomic browsers against each other and against the information you were able to get from NCBI resources
.
Main Java[All of the Base Concepts}.docxadhitya5119
This is part 1 of my Java Learning Journey. This Contains Custom methods, classes, constructors, packages, multithreading , try- catch block, finally block and more.
Walmart Business+ and Spark Good for Nonprofits.pdfTechSoup
"Learn about all the ways Walmart supports nonprofit organizations.
You will hear from Liz Willett, the Head of Nonprofits, and hear about what Walmart is doing to help nonprofits, including Walmart Business and Spark Good. Walmart Business+ is a new offer for nonprofits that offers discounts and also streamlines nonprofits order and expense tracking, saving time and money.
The webinar may also give some examples on how nonprofits can best leverage Walmart Business+.
The event will cover the following::
Walmart Business + (https://business.walmart.com/plus) is a new shopping experience for nonprofits, schools, and local business customers that connects an exclusive online shopping experience to stores. Benefits include free delivery and shipping, a 'Spend Analytics” feature, special discounts, deals and tax-exempt shopping.
Special TechSoup offer for a free 180 days membership, and up to $150 in discounts on eligible orders.
Spark Good (walmart.com/sparkgood) is a charitable platform that enables nonprofits to receive donations directly from customers and associates.
Answers about how you can do more with Walmart!"
Chapter wise All Notes of First year Basic Civil Engineering.pptxDenish Jangid
Chapter wise All Notes of First year Basic Civil Engineering
Syllabus
Chapter-1
Introduction to objective, scope and outcome the subject
Chapter 2
Introduction: Scope and Specialization of Civil Engineering, Role of civil Engineer in Society, Impact of infrastructural development on economy of country.
Chapter 3
Surveying: Object Principles & Types of Surveying; Site Plans, Plans & Maps; Scales & Unit of different Measurements.
Linear Measurements: Instruments used. Linear Measurement by Tape, Ranging out Survey Lines and overcoming Obstructions; Measurements on sloping ground; Tape corrections, conventional symbols. Angular Measurements: Instruments used; Introduction to Compass Surveying, Bearings and Longitude & Latitude of a Line, Introduction to total station.
Levelling: Instrument used Object of levelling, Methods of levelling in brief, and Contour maps.
Chapter 4
Buildings: Selection of site for Buildings, Layout of Building Plan, Types of buildings, Plinth area, carpet area, floor space index, Introduction to building byelaws, concept of sun light & ventilation. Components of Buildings & their functions, Basic concept of R.C.C., Introduction to types of foundation
Chapter 5
Transportation: Introduction to Transportation Engineering; Traffic and Road Safety: Types and Characteristics of Various Modes of Transportation; Various Road Traffic Signs, Causes of Accidents and Road Safety Measures.
Chapter 6
Environmental Engineering: Environmental Pollution, Environmental Acts and Regulations, Functional Concepts of Ecology, Basics of Species, Biodiversity, Ecosystem, Hydrological Cycle; Chemical Cycles: Carbon, Nitrogen & Phosphorus; Energy Flow in Ecosystems.
Water Pollution: Water Quality standards, Introduction to Treatment & Disposal of Waste Water. Reuse and Saving of Water, Rain Water Harvesting. Solid Waste Management: Classification of Solid Waste, Collection, Transportation and Disposal of Solid. Recycling of Solid Waste: Energy Recovery, Sanitary Landfill, On-Site Sanitation. Air & Noise Pollution: Primary and Secondary air pollutants, Harmful effects of Air Pollution, Control of Air Pollution. . Noise Pollution Harmful Effects of noise pollution, control of noise pollution, Global warming & Climate Change, Ozone depletion, Greenhouse effect
Text Books:
1. Palancharmy, Basic Civil Engineering, McGraw Hill publishers.
2. Satheesh Gopi, Basic Civil Engineering, Pearson Publishers.
3. Ketki Rangwala Dalal, Essentials of Civil Engineering, Charotar Publishing House.
4. BCP, Surveying volume 1
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This document provides an overview of wound healing, its functions, stages, mechanisms, factors affecting it, and complications.
A wound is a break in the integrity of the skin or tissues, which may be associated with disruption of the structure and function.
Healing is the body’s response to injury in an attempt to restore normal structure and functions.
Healing can occur in two ways: Regeneration and Repair
There are 4 phases of wound healing: hemostasis, inflammation, proliferation, and remodeling. This document also describes the mechanism of wound healing. Factors that affect healing include infection, uncontrolled diabetes, poor nutrition, age, anemia, the presence of foreign bodies, etc.
Complications of wound healing like infection, hyperpigmentation of scar, contractures, and keloid formation.
1. Chapter 5
Subacute and
Postacute Care
Learning Objectives
1. Define and describe subacute
and postacute care
2. Identify where subacute care fits
in the continuum of care
3. Identify sources of financing for
subacute care
Learning Objectives (continued)
4. Identify and describe regulations
affecting subacute care
5. Identify and discuss ethical issues
affecting subacute care
6. Identify trends affecting subacute
care for the near future and the
impact of those trends
2. What is Postacute Care?
Postacute care:
the community
additional support following
discharge from the hospital
Postacute Care Providers
Include:
n facilities
-term care hospitals
What is Subacute Care?
-term care
time
Philosophy of Care
3. Four types:
-term transitional
Ownership of Subacute Facilities
-thirds)
• Rehabilitation focus
-based
• Medical focus
Services Provided
• Rehabilitation • Chemotherapy
• Physical therapy • Parenteral nutrition
• Occupational therapy • Dialysis
• Respiratory therapy • Pain management
• Cardiac rehabilitation • Complex medical care
• Speech therapy • Wound management
• Postsurgical care• Ventilation care
4. • Other specialty care
Care Planning
tion
Case Management
-effectiveness
at lowest cost
• “External” – hired by payer
• “Internal” – hired by provider
Consumers of Subacute Care
-replacement surgery
6. Financing Subacute Care
Reimbursement Sources:
– two-thirds
• Pays as SNF
• Managed care
• Medicaid
• Private insurance, self-pay, and other
Staffing
Interdisciplinary team:
or
Legal and Ethical Issues
Management Qualifications
facility administrators
7. -based units must find a
licensed administrator or get one of the
hospital administrators licensed
Management Challenges
and Opportunities
organization
considerations
Significant Trends
Summary
Subacute care is the newest form of long-term
care, falling between acute and long-term care.
Slide 1Learning ObjectivesLearning Objectives
(continued)What is Postacute Care?Postacute Care
ProvidersWhat is Subacute Care?Philosophy of CareOwnership
of Subacute FacilitiesServices ProvidedCare PlanningCase
ManagementConsumers of Subacute CareMarket
8. ForcesRegulationsTypes of RegulationsAccreditationFinancing
Subacute CareStaffingLegal and Ethical IssuesManagement
QualificationsManagement Challenges and
OpportunitiesSignificant TrendsSummary
CHAPTER 5
Subacute and Postacute Care
Learning Objectives
After completing this chapter, readers will be able to:
1. Define and describe subacute and postacute care for the
purpose of clarifying these confusing terms.
2. Identify where subacute care fits in the continuum of care,
the services it offers, and the consumers who use it.
3. Identify sources of financing for subacute care.
4. Identify and describe regulations affecting subacute care.
5. Identify and discuss ethical issues affecting subacute care.
6. Identify trends affecting subacute care for the near future,
and describe the impact of those trends.
■ Introduction
This chapter describes subacute (and postacute) care—an often-
misunderstood segment of the continuum of care—discussing its
development, reasons for that development, and where it
currently fits in the continuum, as well as the nature of the
consumers who use subacute care and what they seek from it. It
is misunderstood because it contains several elements that
frequently overlap and are referenced by different names. The
terms
subacute care and
postacute care cover some, but not all, of the same
services. In fact, discussing both subacute care and postacute
care in the same chapter could be called arbitrary. However, we
do so in an attempt to bring some clarity to the issue.
We discuss postacute care primarily in the context of explaining
the terminology. The chapter explores issues related to
9. financing, staffing, and regulation as they impact subacute care,
and it identifies several trends promising such impact in the
future.
■ What Is Postacute Care?
Postacute care (PAC)
is designed to improve the transition from hospital to the
community. Post-acute care includes the recuperation,
rehabilitation, and nursing services following a hospitalization
that are provided in skilled nursing facilities (SNFs), inpatient
rehabilitation facilities (IRFs), and long-term care hospitals
(LTCHs), and by home health agencies (HHAs) and outpatient
rehabilitation providers. (Dummit, 2011, p. 3)
■ What Is Subacute Care?
While we get to a more detailed definition of subacute care
later, for now let us use a simple, straightforward definition. It
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” (CA Subacute Care Unit, 2012). One
author suggests we think of subacute care as:
a passageway through which increasing numbers of patients
travel. What happens during that experience can range from a
set of basic rehabilitation services to a much richer array of
therapy, teaching, and medical progress. Medical, and often
psychosocial, complexity characterizes subacute care.
(Buxbaum, 2009)
■ What Is the Difference Between Postacute Care and Subacute
Care?
Both subacute and postacute care are substitutes for acute care,
resulting in less cost to the system and to third-party payers and
in more convenience for the patient. However, there are
differences as shown by the following:
Subacute Care
Postacute Care
May be either after or in place of acute care
Happens after acute care
10. Provides inpatient services
Provides outpatient services
Provides medical and nursing care
Provides nursing and/or nonmedical care
Postacute care may even be provided following subacute care as
an outpatient follow-up to inpatient subacute care.
■ Postacute Care
We begin this discussion with a look at who provides postacute
care. Postacute care may be provided in or by several different
types of providers, including the following:
• Inpatient rehabilitation hospitals and units
• LTCHs
• Skilled nursing facilities
• Home health agencies (CMS, 2012)
Each of the multiple PAC settings specializes in certain types of
care and therapies, allowing patients to receive a diverse array
of services ranging from intensive medical, rehabilitation, and
respiratory care to in-home follow-up, such as changing
dressings or administering medication. Patients receive a unique
set of services in each PAC setting, though some services may
be available in more than one setting. Selecting the most
appropriate setting for a given patient may involve multiple
factors. Some patients may benefit from care at multiple PAC
settings during a single episode of illness (AHA, 2010).
Because both skilled nursing facilities and home health agencies
are discussed in detail elsewhere, we discuss them here only as
they relate to the others in postacute care or subacute care. Let
us examine the other two categories (inpatient rehabilitation
facilities and long-term care hospitals) here. It is also worth
noting that postacute care may also be provided in outpatient
settings and adult day care. However, these services are not
covered by Medicare and are not significant in terms of the
number of patients utilizing them as postacute care.
Inpatient Rehabilitation Facilities
In a broad sense, rehabilitation services are measures taken to
promote optimum attainable levels of physical, cognitive,
11. emotional, psychological, social, and economic usefulness and
thereafter to maintain the individual at the maximal functional
level. The term is used to denote services “provided in inpatient
and outpatient settings, ranging from comprehensive,
coordinated, medically based programs in specialized hospital
settings to therapies offered in units of hospitals, nursing
facilities, or ambulatory centers” (AHA, 2013). Subacute
rehabilitation care provides continuity of care for patients who
no longer require hospitalization but still need skilled medical
care in a rehabilitation facility. Subacute rehabilitation is
recommended when a patient is not functionally able to return
home. Instead, during recuperation, patients receive
rehabilitation in a skilled nursing facility. Medicare requires
that skilled nursing facilities provide an intensive rehabilitatio n
program, and patients who are admitted must be able to tolerate
3 hours of intense rehabilitation services per day. For
classification as an IRF, a percentage of the IRF’s total patient
population during the IRF’s cost reporting period must match 1
or more of 13 specific medical conditions (CMS, 2012).
In 2001, the Centers for Medicare & Medicaid Services (CMS)
published a prospective payment system (PPS) for Medicare
IRFs as required by the Balanced Budget Act of 1997. The
payment system, which became effective January 1, 2002,
significantly changed how inpatient medical rehabilitation
hospitals and units are paid under Medicare.
The number of inpatient rehabilitation facilities declined
slightly in 2009 after remaining stable for several years before
that (MedPac, 2013).
Long-Term Care Hospitals
LTCHs “typically provide extended medical and rehabilitative
care for patients who are clinically complex and may suffer
from multiple acute or chronic conditions. Services may include
comprehensive rehabilitation, respiratory therapy, cancer
treatment, head trauma treatment, and pain management” (CMS,
2012, p. 7).
LTCHs are certified as hospitals, meeting the same minimum
12. staffing requirements, range of services, and life-safety
standards. In addition, LTCHs are required to have an average
Medicare length of stay of more than 25 days, which is intended
to ensure that their patients are medically complex. LTCHs that
are located within an acute care hospital—the fastest growing
segment of these providers—are subject to additional
requirements that limit the share of their patients admitted from
the host hospital. The number of LTCHs rose from 278 in 2001
to 432 in 2009. In spite of a moratorium on new LTCHs
beginning in October 2007, the number of these facilities
continued to grow through 2010, then remained constant from
2011 to 2012 (MedPac, 2013). In some areas of the country
where they are not available, acute care hospitals and SNFs
substitute (Dummit, 2011). IRFs are either freestanding
facilities, sometimes called rehabilitation hospitals, or
rehabilitation units located within acute care hospitals (Singh,
2010).
While Medicare covers LTCHs, there has been concern that they
are not an efficient use of resources. Although each of the other
types of postacute care (IRFs, skilled nursing facilities, and
home health) has standardized data collection and systems, no
assessment instrument is mandated for LTCHs (CMS, 2012).
Use of Postacute Care
About one-third of hospital patients go on to use postacute care.
The most common, single, postacute care destination for
beneficiaries discharged from acute inpatient care hospitals is a
skilled nursing facility. Although some episodes involve
multiple settings, they generally include only one postacute
setting (MedPac, 2013).
Medicare Conditions of Participation
Postacute providers must also meet different conditions of
participation. For example, physicians must be integrally
involved in care provided in rehabilitation facilities and long-
term care hospitals, but are required to visit an SNF patient only
once every 30 days for the first 90 days and every 60 days
thereafter. Requirements for physician involvement in home
13. health care are even less stringent.
Rehabilitation facilities are required to have 75% of their
admissions in 1 of 10 specific diagnoses related to conditions
requiring rehabilitation services. LTCHs’ only condition of
participation in addition to those required of all hospitals is to
have an average Medicare length of stay greater than 25 days
(MedPac, 2013).
As one can see, Medicare is a major factor influencing
postacute care services due to its reimbursement of those
services and the rules that go with that reimbursement.
Postacute care currently makes up about 11% of Medicare’s
total spending (MedPac, 2013). The CMS has been concerned
that the system for reimbursing and monitoring postacute care is
poorly defined and contains some inconsistencies, and it has
implemented a postacute care reform plan. That plan calls for a
demonstration project to assess the system and develop reforms
(MedPac, 2013).
Bundled Payments
Like other Medicare-certified providers, postacute care
providers will be impacted by the CMS’s Bundled Payments for
Care Improvement initiative. Under the Bundled Payments
initiative, organizations known as accountable care
organizations will enter into payment arrangements that include
financial and performance accountability for episodes of care.
The hospital-based accountable care organizations will receive
the Medicare payments for all other services and will contract
with long-term care providers for postacute care. Medicare will
pay the accountable care organizations for covered services
delivered during an episode of care that is initiated with a
hospitalization and continues for 30 days after discharge
(Dummit, 2011). The accountable care organizations will then
pay the contracted providers and will be held accountable by the
CMS for the quality outcomes associated with this postacute
care.
Readmissions
The Affordable Care Act of 2010 reduces payments to hospitals
14. for greater-than-expected readmissions, decreasing payments for
all Medicare discharges in the prior year. Acute care hospitals
and PAC providers will work to reduce rehospitalizations
(AHA, 2010).
■ Subacute Care
Having hopefully clarified the terms
subacute care and
postacute care, we focus the remainder of this chapter
on subacute care, referencing postacute care as needed.
How Did Subacute Care Come to Be?
Subacute care is probably one of the newest entries into the
continuum of care. (
Probably is used here because of the rapidity with
which new types of care and mutations of established types of
care are emerging.) It is also one of the fastest growing
segments of the healthcare delivery system. Over the past
several decades, it has grown and developed, slowly at first,
then more rapidly. It has also become somewhat better defined.
At first, it was best defined by what it was not. It was not really
acute care, nor was it long-term care. It was pretty much
anything that fell in between the two. As the healthcare field
reacted to the forces at work on it during the 1980s and 1990s
(forces such as pressures to be cost effective, increased demand
for consumer choice, and competition between providers),
subacute care found its niche. It became a defined service
instead of a somewhat nebulous gap filler.
Defining Subacute Care
Subacute care
includes post-acute services for people who require
convalescence from acute illnesses or surgical episodes. These
patients may be recovering but are still subject to complications
while in recovery. They require more nursing intervention than
what is typically included in skilled nursing care. (Singh, 2010,
p. 15)
15. It 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. Subacute patients are medically fragile
and require special services, such as inhalation therapy,
tracheotomy care, intravenous tube feeding, and complex wound
management care. Pediatric subacute care is a level of care
needed by a person less than 21 years of age. These patients
generally use medical technology to compensate for the loss of
a vital bodily function (CA Subacute Care Unit, 2012).
Philosophy of Care
Subacute care is specific care rendered for very specific
reasons. Conditions that may be appropriate for inpatient
subacute care include but are not limited to:
• Cardiac recovery
• Oncology recovery—receiving chemotherapy and radiation
• Pulmonary conditions
• Orthopedic rehabilitation
• Neurological disorders/cerebrovascular accident
• Complex wound management
• Intravenous therapy (Anthem, 2013)
Initially, subacute care was seen as a form of postacute care, or
treatment rendered immediately after acute hospitalization.
Over time, it also began to be used in place of acute
hospitalization, both as a cost-saving measure and in the
interests of providing treatment in the least restrictive location
and manner.
It is generally thought of as a transitional phase of care, moving
the patient to home or to a long-term care facility in a short
time. However, there are other variations. There seem to be four
generally agreed-upon categories of subacute care, best defined
by Kathleen Griffin in her
Handbook of Subacute Care, which has become the
authority on the subject (Griffin, 1995). The first category she
identifies is transitional subacute care, which is usually quite
short term, serving as a means of transitioning from highly
16. intensive hospital units while maintaining the availability of
acute care if needed. As such, transitional units are usually
located at or near hospitals and operated by those hospitals.
A second type of subacute care is referred to as general
subacute care. Lengths of stay are somewhat longer for those
receiving general subacute care than those in transitional units.
Patients needing ongoing therapy or monitoring fall into this
group. General subacute care units are apt to be owned and
operated by either hospitals or nursing facilities (Griffin, 1995).
The third category is chronic subacute care. These units care for
patients with serious chronic conditions requiring services such
as ventilator or intravenous therapy. Their average stay is
longer than the transitional or general subacute care units, but
most patients stay only about 60 to 90 days before they are
transferred to a lower level of care or before they die (Griffin,
1995).
The last category described by Griffin is long-term transitional
subacute care. It is usually hospital-based care for patients with
more complex medical problems who need more intensive (but
still not acute) care over a longer time before transitioning to
home or another level of care (Griffin, 1995).
Thus, subacute care, as a portion of the continuum, is best
defined in terms of the type, amount, and duration of care
given. There is emphasis on staff with skills in assessment of
patients’ conditions and the ability to adjust treatment plans as
needed. They must also be skillful at managing specific
conditions such as strokes or post–cardiac surgery and in
performing specific procedures such as ventilator therapy or
pain management. Although Griffin’s book is 2 decades old,
these categories and definitions are still valid and one of the
best ways to differentiate the various forms of subacute care.
Ownership of Subacute Care Units
As noted earlier, subacute care is identified by the services
offered, not necessarily by who the providers are. Often,
subacute care is provided by existing hospitals or freestanding
17. nursing facilities. Increasingly, both groups are becoming part
of integrated healthcare networks. Subacute care units, when
affiliated with hospitals or nursing facilities, are usually
classified as SNFs by Medicare for reasons of reimbursement
and are often the result of reclassifying beds in a designated
unit.
Freestanding SNFs are the most prevalent form of subacute
care, followed by hospital-based units. The hospital-based units
generally function as swing-bed units, allowing the patient to
change classification without actually moving.
An important trend in ownership of subacute care units, a trend
supported by all available studies, is the large proportion owned
and operated by chains, either regional or national. They have
the financial resources and staff expertise to develop and
operate such services where many independent owners do not.
Services Provided
Services provided in subacute care units vary depending on the
nature of the population served, but might include the
following:
• Rehabilitation
• Physical and occupational therapy
• Respiratory therapy
• Cardiac rehabilitation
• Speech therapy
• Postsurgical care
• Chemotherapy
• Total parenteral nutrition
• Dialysis
• Pain management
• Complex medical care
• Wound management
• Ventilation care
• Other specialty care
Planning how care will be delivered to consumers is important
in all forms of health care, but the terms
care planning and
18. case management have taken on more importance in
subacute care than in some of those others, largely due to the
influence of reimbursement sources. Care planning is discussed
next; case management will be discussed later in this chapter.
Care Planning
A key to successfully providing subacute care is good care
planning. It involves assessing each individual patient’s needs,
developing a care plan to meet those needs, and constantly
reviewing the care plan and adjusting it as needed. If not done
carefully, by qualified staff, care planning may produce
negative results, including longer-than-necessary lengths of stay
or inadequate treatment. The former results in excessive costs to
the organization. The latter leads to dissatisfied patients, which,
in turn, may lead to dissatisfied reimbursement organizations.
The care plan begins with a detailed assessment of each patient.
Members of the interdisciplinary team must have assessment
skills in addition to knowing how to provide specific
treatments. The entire team is involved in the assessment
process, and each member has something specific to offer. It is
their collective evaluation that results in a good care plan.
Together, they develop care goals for the patient—goals that
might focus on returning the patient to home, improving or
maintaining the level of functional independence, stabilizing a
medical condition, or any of a variety of similar end results.
Those goals must be accurately defined and clearly understood
by all involved, including the patient.
There must be clearly established admission criteria to
determine the parameters within which the team may work.
Those criteria should be explicit and include definitions of the
types of patients and patient conditions for which the facility is
qualified to care.
Care planning by the interdisciplinary team is not a one-time
occurrence. It goes on throughout the course of treatment. It is
generally recognized that the team will hold care-planning
conferences to review the plan and the patient’s progress at
19. least weekly, more often if the patient’s medical or functional
status changes. It must be a dynamic process, capable of quickly
identifying and assessing changes and responding to them in a
timely and appropriate manner, which requires that the team
members be skilled in assessment techniques.
These interdisciplinary team meetings should include all who
are involved in the patient’s care, as well as the patient, family
members, and other caregivers. It is an information-sharing
session as well as an opportunity to evaluate progress against
the original care plan.
The care plan, including the assessment on which it is based and
the periodic evaluation and adjustments of that plan, does not
represent the end of the process by a long shot. To be
successful, subacute care must include an outcomes-based
measure of how well the program met its goals. There must be a
process for determining the effectiveness of the treatment plan.
That effectiveness is measured by changes in the patient’s
medical or functional status from the beginning of the program
to the end. It also includes periodic measurement against
predetermined benchmarks during the treatment process.
Measuring Quality of Care
There are numerous excellent tools available for measuring
outcomes-based effectiveness. For example the CARF
International (formerly the Commission on Accreditation of
Rehabilitation Facilities) program evaluation system contains
excellent processes for measuring functional outcomes.
Providers have also dealt with a couple of other programs:
quality assurance and continuous program improvement—also
known as program improvement—that have been replaced by
quality assurance and performance improvement (QAPI).
QAPI
QAPI is the merger of two complementary approaches to
quality: quality assurance and performance improvement. Both
involve seeking and using information, but they differ in key
ways:
• Quality assurance is a reactive, retrospective process of
20. meeting regulatory quality standards.
• QAPI is a proactive and continuous study of processes with
the intent to prevent or decrease the likelihood of problems by
identifying areas of opportunity and testing new approaches to
fix underlying causes of persistent/systemic problems.
QAPI is a data-driven, proactive approach to improving the
quality of life, care, and services in nursing homes. According
to the CMS, the activities of QAPI “involve members at all
levels of the organization to: identify opportunities for
improvement; address gaps in systems or processes; develop and
implement an improvement or corrective plan; and continuously
monitor effectiveness of interventions” (CMS, 2013).
Whatever process, or combination of processes, a subacute care
program chooses to utilize, there must be a method of
measuring what the program accomplished on behalf of its
patients. Patients will seek that information, as will agencies
providing reimbursement, and any licensing or accreditation
organizations involved. Even if they did not, the provider needs
to know how well it is performing. Anecdotal evidence of
patient satisfaction is valuable but should be supported by some
type of tangible, quantifiable confirmation that the program is
producing the results it expects and promises.
Outcomes measurement should not stop at discharge. Most
subacute care services are aimed at producing results that will
improve the patient’s medical or functional status. If effective,
those results will last, at least for a reasonable period. Yet, the
very nature of the conditions being treated causes those results
to diminish over time. An effective outcomes measurement
program will extend beyond discharge far enough to document
how well the treatment results lasted, usually at least 90 days. It
provides the program with information about how well the
patient was prepared for discharge, indicating the efficacy of
follow-up arrangements and the preparation of the patient to
continue treatments or to maintain the functional or medical
status achieved while receiving subacute care.
Both quality and cost outcomes should be measured. It is
21. obviously important that the quality and efficacy of care be
proven. However, payment sources, particularly managed care
organizations (MCOs), expect subacute care providers to
document their efficiency as well.
Postdischarge measurement also provides a mechanism for
detecting problems with the discharge planning process and
sometimes with the plans themselves. It identifies potential
slippage in the patient’s status, indicating the need for further,
more intense intervention. As such, it is an integral part of the
entire treatment process. Just as there must be clear criteria for
admission to the subacute care organization, so must there be
criteria for discharge. The unit must have transfer agreements
with appropriate facilities so that the care-planning team is able
to discharge appropriately and in a timely fashion, without
unnecessary delays or gaps in coverage.
Case Management
There is another element in managing the process of provi ding
subacute care. It is case management, not to be confused with
care management. While care management is concerned with the
type and quality of care received, case management’s primary
goal is the cost-effectiveness of the care given.
The actual process of case management parallels the care-
planning process, with many similarities. In fact, the case
manager is an integral part of the interdisciplinary team and is
involved each step of the way. The difference is that the case
manager’s focus is more on the degree of efficiency with which
care is given. He or she manages the utilization of resources
expended in providing care.
Case managers are often employed by payers, particularly
MCOs, to protect their interests. Those external case managers
often have powers to approve or disapprove treatment, including
specific procedures. They seek to control high-cost procedures,
limiting or eliminating expenses deemed unnecessary.
There may not always be an external case manager in subacute
care, depending on the payer, but there will usually be an
internal case manager employed by the unit. That person’s job
22. involves both patient outcomes and cost. The internal case
manager is more closely involved with the patient care team
than the external case manager is likely to be. In fact, one major
role of the unit’s case manager is to act as a liaison with the
case manager employed by the payer and to negotiate with the
payer’s representative to secure authorization and payment for
needed supplies, equipment, and procedures. He or she also
functions as a liaison with other entities, including the clinical
team, the patient, and the patient’s family. Lastly, do not get the
impression that the subacute care organization’s case manager
is only concerned with minimizing costs. That person is also the
patient’s advocate. A clinical background is very useful.
The role requires a combination of coordination, monitoring,
and control. The internal case manager must be knowledgeable
of the rules governing payment for services and must keep up
with any changes in eligibility or coverage provisions that
would affect reimbursement to the provider.
The use of case managers by the providers and payers has
become standard practice in subacute care and some other types
of health care. It is based on a sound philosophy of managing
the process of providing care to ensure that it is efficient, cost
effective, and not unnecessarily expensive. However, it raises
certain questions and has led to some disagreement and
controversy, particularly among healthcare policy makers. The
case manager functions as a gatekeeper—the person who
controls access to care. Who should be the gatekeeper? Can
anyone objectively serve the three principal participants (the
patient, the provider, and the payer)? When the gatekeeper
works for the provider, the payer worries that unneeded services
will be provided to generate revenue. At the same time, the
patient worries that the provider will skimp on services to save
expenses. If the payer employs the gatekeeper, the provider and
patient both worry that cost will take precedence over quality or
even over required care. Lastly, if the patient or a surrogate (an
ombudsman, legal representative, or other advocate) serves as
gatekeeper, the provider and payers fear excessive use of
23. services at their expense.
Who should be the gatekeeper? There is no easy answer.
Perhaps the most effective, but certainly not the neatest or most
efficient, solution lies in having three gatekeepers who each
represent one of the parties. Through a system of checks and
counterchecks, they keep each other in balance. The one who is
most likely to be at a disadvantage is the patient, who has to
rely to some degree on the good faith and honorable intentions
of the others to act in his or her best interests. It is an
interesting dilemma and one for which subacute care may be
leading the way toward a system that comes closest to a
solution. The relative newness of subacute care leaves more
room for experimentation and innovation than some of the more
traditional segments of health care. The major role played by
MCOs in subacute care, when compared with nursing facilities,
home care, and other forms of long-term care, is also increasing
the popularity of case management. It is a concept that is here
to stay, although its shape may change many times over the next
few years.
Consumers Served
Subacute care serves a variety of types of patients, but it tends
to treat more of some types than others. They are patients
needing a high level of skilled care, generally with a defined
treatment plan and timetable for discharge or transfer to another
type of care. They need rehabilitation, monitoring, or other
specialized treatment. People of all ages require and receive
subacute care, but as with most long-term care, the majority are
elderly.
■ Market Forces Affecting Subacute Care
Subacute care has grown in response to several factors in the
healthcare environment.
Cost-Saving Efforts
The primary force has been financial. With the replacement of
the historical, retrospective, cost-based method of reimbursing
hospitals by a PPS, hospitals came under considerable pressure
to keep lengths of stay in acute care as short as possible. At the
24. heart of PPS was a system of diagnosis-related groups. Under
the system of diagnosis-related groups, hospitals were being
reimbursed for the episode of illness, not by the day. They
sought ways to discharge patients earlier or to find less
expensive settings for them. This set up a general movement
within the healthcare system of patients to a lower level of care
intensity. It, in turn, raised the acuity level of patients/residents
at each level. Subacute patients did not need the high-end acute
services offered by hospitals but needed more than traditional
nursing facilities were equipped to provide.
Providers and reimbursement agencies alike quickly realized
that a care/payment category in the middle made sense.
Reimbursers—primarily Medicare—were able to pay a lower
rate for subacute services than they would for acute care.
Hospitals received a rate lower than their acute rate but more
than a nursing care rate.
Diagnosis-related groups created another market force that also
led to creation of more subacute care units. Hospitals found
themselves, many for the first time, with low occupancy rates
and entire units of empty beds. Creation of a new, in-between,
level of care enabled them to fill some of those beds. It also
allowed them to legitimately keep patients longer. By
converting acute patient units to subacute care, they were able
to make more efficient and effective use of their expensive
buildings, equipment, and staff. The bundled payments program
of the Affordable Care Act places more emphasis on
coordination of effort between acute and subacute providers in
reducing costs.
Managed Care
The most important market force driving the growth of subacute
care, however, has been the emergence and rapid expansion of
managed care. MCOs have found subacute care to be an
excellent resource for them in their quest to find lower cost
alternatives to acute hospitals.
Nursing care facilities have also found reasons to enter the
subacute care arena, including making themselves attractive to
25. MCOs. Their administrators are faced with both an opportunity
and a challenge to meet higher demands for managed care
(Singh, 2010).
Medicare and MCOs were not the only reimbursers seeking
ways to reduce their costs. Others, such as private insurance
companies, spurred on by their corporate customers, were also
reacting to major increases in the cost of providing and insuring
health care. They sought mechanisms for controlling those
costs, including mandatory second opinions and preadmission
authorization. Subacute care gave them an opportunity to cover
needed care for their policyholders at a lower cost.
Many nursing facilities also foresaw the competition coming
from hospitals and decided to get into subacute care as a means
of expanding, or at least maintaining, their market share. Others
were not as proactive, but many of them have come to realize
that subacute care is an area that they can share with hospitals
or be left out.
Choice
Another, nonfinancial force affecting the growth of subacute
care was the rising demand by healthcare consumers for more
choice in their care. They made it very clear that they want as
much care as is necessary but do not want to be in what they see
as more restrictive acute hospitals if it is not needed. Again,
subacute care units provide them with a middle-ground
alternative.
■ Regulations
Subacute care was created in part because of regulations
(primarily those associated with the prospective payment
system); thus, has it been further shaped and defined by
regulations. Subacute care is similar to other parts of the
continuum of care in that it is governed by a plethora of
regulations. It is, however, somewhat different from the more
established entities such as hospitals and nursing facilities
because of its relative newness. It is still somewhat immature as
a regulated industry segment, but it is rapidly catching up with
the other provider groups.
26. Just as subacute care is neither hospital care nor nursing facility
care as such, it has been treated as a kind of hybrid by
regulators. Hospital regulations do not fit it well. Although
applied to subacute care, they have not adequately met the
needs of either providers or regulators in that area. Nor have
nursing facility regulations. Those regulations were designed
for other types and levels of care, with different patient
populations, care goals, and staffing. Healthcare regulations
dealing with quality of care, reimbursement, and management of
one type of provider cannot readily be applied to another in a
one-size-fits-all manner. That is particularly true when there are
already several different sets of regulation applying to older
types of service providers.
For example, federal law requires that all nursing facility
administrators be licensed in their respective states, but there is
no such regulation applicable to hospital administrators. If
subacute care fits somewhere in between, should their
administrators be licensed or not?
There is need for regulations tailored to subacute care. It is an
established form of healthcare service. Although newer than
most others, it has enough of a track record for regulators to use
to create appropriate regulations that protect consumers from
poor quality and the government from excessive costs. Current
regulations do neither adequately. Yet, because they are being
applied, they often serve as obstacles to providers who are
trying to further refine this growing field.
Other regulations to which subacute care providers are subject
come from several different sources, as do those covering other
types of health care. However, the lack of subacute-specific
regulations muddies the waters even more.
Medicare certification regulations cover areas such as staffing,
length of stay, organizational form, patients’ rights, and
required services. Subacute care providers find it difficult to
comply with them because there are discrepancies from one type
of provider to another in some of those regulations.
Other regulations applying to subacute care are those associated
27. with the Omnibus Budget Reconciliation Act of 1987 (OBRA).
Also referred to as the Nursing Home Reform Act, OBRA made
major changes in the long-term care industry. Its rules, which
are very prescriptive concerning such things as facility design,
staffing patterns, care plans, and services provided, are much
more rigid than those to which hospitals are accustomed.
However, they have been determined to apply to all SNFs
certified by Medicare, including hospital-based units. Hospitals
have found themselves hard pressed to conform to those more
definitive regulations.
Medicaid regulations also affect subacute care providers,
although they vary from state to state. There are often crossover
regulations affecting both Medicare and Medicaid, particularly
in terms of eligibility.
Subacute care providers are also subject to certificate of need
(CON) regulations where CON laws still are in effect.
Certificate of need laws were first passed to control new capital
expenditures and services. The purpose of such laws was to
limit overall healthcare spending by limiting expansion of
services or the building of healthcare facilities. They have been
scrapped in many states, but in those states still enforcing CON
regulations, subacute care providers must go through a lengthy,
and often expensive, review process in order to get approval to
create a new subacute care service. Some states have created a
virtual moratorium on certain types of new construction.
Providers wishing to open a new unit then have to buy a CON
approval from another provider, purchase an existing facility’s
licensed bed complement, or gain that approval through a joint
venture with an organization that has already received such
approval. It is not uncommon for potential subacute providers to
avoid states with restrictive CON laws still in effect.
While inapplicable, fragmented regulations are the bane of any
provider’s existence, and the situation in subacute care is
particularly bad, do not think that those providers are not
capable of taking advantage of that confusion. They, like
providers in any highly regulated industry, know where to find
28. the loopholes and are surprisingly adept at leveraging the
system to their advantage, which may lead to some unfortunate
gamesmanship between regulators and the regulated, such as the
purchase of CONs as just described. Also, some providers have
taken advantage of the inability of regulations in those
programs to prevent abuses. In response, the CMS—formerly
the Health Care Financing Administration—implemented an all-
out effort to make changes needed to stop them (Hyatt &
Cornish, 1997). It was a laudable effort, but one that might have
been avoided, at least in part, if a similar level of effort had
been devoted to developing clear, applicable regulations to this
new segment of the industry.
Some states have looked at separate regulations for subacute
care but have not addressed subacute care directly. This only
added to the already high level of uncertainty pervading the
field of subacute care. Reform efforts have, however, often
resulted in an increase in managed care, including coverage of
public constituencies such as Medicaid patients. Those efforts,
based in large part on a desire to save money, have indirectly
benefited subacute care.
Before leaving this brief look at regulations, it should be noted
that subacute care providers are also subject to other types of
regulations just as are other healthcare providers and, in most
cases, other industries. They are subject to regulations
affecting employment and treatment of their staff that come
from sources such as the Occupational Safety and Health
Administration, the Wage and Hour Division of the U.S.
Department of Labor, the Equal Employment Opportunity
Commission, worker’s compensation acts, the Americans With
Disabilities Act, the Fair Labor Standards Act, the Family
Medical Leave Act, and others.
They must also comply with regulations affecting building
construction/safety such as the Life Safety Code and local
building codes. The Occupational Safety and Health
Administration and Americans With Disabilities Act also
contain regulations concerning building construction and safety.
29. ■ Accreditation
Voluntary accreditation and certification is much further ahead
than regulation in attempting to ensure quality in subacute care.
The Joint Commission (formerly the Joint Commission on
Accreditation of Healthcare Organizations) and CARF
International both took the early lead in implementing subacute
care quality standards.
The Joint Commission, instead of developing an entirely new
set of standards for subacute care, took portions of its existing
hospital and long-term care standards and adapted them to fit
this in-between level of care. Actually, the standards are
changed little if at all, but the interpretation of those standards,
on which the survey is based, was tailored to reflect differences
in staffing, care plans, and physical facility requirements. It has
worked surprisingly well, although it is not as refined as
subacute-specific standards would probably be.
CARF International took a somewhat different approach. It was,
after all, focused on rehabilitation and had considerable
experience in accrediting agencies and organizati ons providing
a variety of rehabilitation services, as compared with the Joint
Commission’s broader healthcare focus. Thus, CARF
International included medical rehabilitation, including
subacute care, under the overall umbrella of comprehensive
rehabilitation programs. Three subcategories were developed,
taking into account the different levels and types of
rehabilitation care (acute or subacute), the provider location
(hospital-based or freestanding skilled nursing facilities), and
patient outcome goals. CARF International standards and survey
processes have long been more outcome oriented than those of
the Joint Commission, but the latter organization has made
significant changes over the past few years to the point where it
is also focused on outcomes. It should be noted here that CARF
International merged with the Continuing Care Accreditation
Commission in 2003, but that did not have any significant
impact on subacute care accreditation.
The National Committee for Quality Assurance (NCQA) is
30. directed primarily at MCOs. However, as subacute care
providers or the parent organizations under which they operate
wish to contract with MCOs, they must be aware of the NCQA
standards, what they are, what they require, and how best to
meet them.
Subacute care provider organizations that are part of MCOs will
have to meet these standards. However, they are not alone.
Other subacute care providers will also have to adopt strategies
designed to comply with NCQA standards if they wish to
compete successfully for managed care contracts.
Subacute care providers are seeking voluntary accreditation at a
much faster pace than are traditional nursing facilities, perhaps
reflecting the influence of hospitals, for whom accreditation is a
long-standing norm. Accreditation is also a valuable credential
for any organization trying to survive in a competitive
marketplace to have. Many subacute care units are accredited by
the Joint Commission, another group is accredited by CARF
International, and a smaller group by state or other accrediting
bodies.
In a business without clear regulations to govern it and
document excellence or the lack of it, accreditation becomes an
even more useful credential to have.
■ Financing Subacute Care
The problems stemming from attempting to use regulations
designed for hospitals and/or nursing facilities with subacute
care also affect the financing of those services. Because
subacute care reimbursement has been in such a state of change,
with new rules and formats occurring regularly and numerous
demonstration projects under scrutiny, we do not get into a lot
of detail about it in this chapter. If we did so, it would probably
be out of date before the reader gets to it. Instead, we present a
broad overview—enough to provide a basic understanding of
how subacute care is financed.
There is no single payer for subacute services, nor is there any
standardized payment mechanism. Medicare and private
insurance are the primary source for subacute nursing home care
31. funding. Medicare pays 68% while private insurance and
individual self-pay account for 22%, with the remainder coming
from other sources such as the patient or his or her family
(ParentGiving, 2013).
Medicare
Just as Medicare had moved from a retrospective, cost-based
payment system to a PPS for acute care hospitals some years
earlier, subacute care made a similar move as the result of the
Balanced Budget Act of 1997. Under the PPS, providers receive
payment based on preestablished rates for specific services
instead of receiving direct reimbursement for their costs.
Managed Care
One trend that does seem to be holding true is the increased
influence of managed care in financing of subacute care. Recent
information suggests that the managed care portion of subacute
care is growing very rapidly. Not only are private
MCOs growing, both in number and in size, but government
programs are also moving in that direction. A majority of states
have been experimenting with managed care for Medicaid
patients as a cost-cutting measure. Several of the federal
initiatives that have been proposed would also encourage
managed care for both Medicare and Medicaid.
■ Staffing and Human Resource Issues
Like most other aspects of subacute care, staffing requirements
fall somewhere between acute care staffing and nursing facility
staffing. There are some basic elements, however, that must be
included. Subacute care requires the coordinated services of an
interdisciplinary team including physicians, nurses, and other
relevant professional disciplines sufficiently trained and
knowledgeable to assess and manage these specific conditions
and perform the necessary procedures (Anthem, 2013).
An Interdisciplinary Team
First, the subacute care provider must adopt a philosophy of
care based on an interdisciplinary team. There must also be an
organizational structure that recognizes that approach and
supports the philosophy, which is not enough in itself. The
32. actual makeup of the team will vary somewhat but would
include a program administrator, a medical director, case
managers, and any or all of the following clinical disciplines:
other physicians, nursing, social services, psychology, physical
therapy, occupational therapy, speech-language pathology,
respiratory therapy, recreation therapy, and dietary.
Program Administrator
There must be someone in charge administratively. That person
might be called program manager, program director,
administrator, or some variation of those titles. What is more
important than the title is the clear responsibility and authority
the person has for operation of the subacute care unit or facility.
The program administrator, as we shall call the position for sake
of simplicity, may have a related clinical background or may be
trained in health care administration. Regardless of background,
the person responsible for running the unit or facility must have
good management skills.
Physicians
Physician coverage and direction is critical to the success of the
subacute care program. There should be a medical director with
designated responsibility for clinical oversight of the program,
ensuring its integrity. The medical director may have other
duties, including direct care of some patients, as long as those
duties do not interfere with his or her primary duties. Ideally,
the medical director will be trained in care of the types of
patients to be treated. A medical rehabilitation unit would do
well to appoint a specialist in internal medicine or a
geriatrician. If the focus is more on physical rehabilitation, a
physiatrist would be preferable; for cardiac rehabilitation, a
cardiologist; and so on. That may not be possible. The unit is
very unlikely to treat only one type of patient; it may be hard to
find a medical director with training appropriate to all of them,
and such specialists are not always easy to find.
Gaps in medical specialty coverage can be filled with other
physicians with the needed specialty training and experience.
They may be hired on a full- or part-time basis, engaged as
33. consultants, or allowed to admit and treat patients as
independent contractors. The choice of method or methods for
providing medical coverage depends on factors such as size of
the program, number and type of services offered, and
availability of physicians with the desired specialties.
Physicians need to visit more often than in the traditional
nursing facility, although generally not as often as in an acute
hospital. The types of services offered and the acuity of the
patients dictate the frequency of physician visits.
Nursing
Nursing coverage is also of critical importance. There must be
24-hour coverage by registered nurses. The actual amount of
nursing care per patient per day depends on the type of
treatment. Patients in transitional medical programs usually
require more than some other rehabilitation patients. Some
highly specialized subacute care, such as that in pulmonary
rehabilitation or neurobehavioral programs, may require
considerably more, even approaching acute staffing levels.
Staffing levels are subject to influence by the source of
reimbursement. Government agencies such as Medicare and
Medicaid have set minimum staffing requirements and
maximum reimbursable expense levels, defining a pretty narrow
range within which the provider must work. MCOs, with their
focus on cost-effectiveness, have their own ideas about staffing.
The provider must be aware of these stipulations, preferably
before getting involved.
Other Professional Staff
Subacute care requires a mix of professional staff, including
therapists, psychologists, social workers, dietitians, and
occasionally others. These disciplines, like the physicians, can
be obtained through several different methods, including direct
hire, consulting, and contracting through an independent
company supplying such services. The volume of patient needs
for a particular service compone nt may not justify employment
of full-time staff in some of these areas—and they may not be
available. In such cases, the program may need to contract with
34. an individual professional or with a contract firm. There are
many excellent contract providers supplying specialty
professionals to hospitals and nursing facilities. However, there
may be disadvantages in using outside sources. For example, it
is always easier to generate consistency of interest and effort
with in-house staff.
Nonlicensed Staff
The subacute unit will also need a committed, well-trained
cadre of nonlicensed workers, including nurse assistants and
staff in housekeeping, maintenance, the business office, and
medical records. They must also be in tune with the overall
philosophy of the subacute program if they are to contribute to
it.
Recruitment
Recruitment of staff is important to the success of the program.
The proper number and mix of staff are needed for efficient
operation. Staff also need to have training in the types of
services provided. Those services may include some highly
specialized treatments, such as dialysis, intravenous therapy, or
wound management. There may be current staff with some of
these capabilities if the subacute care program is being carved
out of an existing facility or organization. If not, or if the
subacute program is an entirely new venture, recruitment
becomes particularly critical and must be given an appropriate
level of attention and support. People with some of these
specialized talents are often difficult to find. In fact, proceeding
with development of a new program without ascertaining the
availability of required staff ahead of time would be foolhardy
at the least and could be disastrous at worst.
The degree to which the organization is able to acquire staff
who already have education and experience will determine how
much additional training is needed. There will always be some
level of training necessary to make sure all staff are equally and
adequately qualified. It must also be an ongoing process to keep
staff sharp and up to date.
■ Legal and Ethical Issues
35. Subacute care providers entering the field of subacute care face
a number of legal issues. Those issues fall into two general
categories: (1) meeting licensure and reimbursement regulations
and (2) professional liability.
Licensure and reimbursement issues revolve around getting
approval to open and operate a subacute care unit and securing
reimbursement for the services provided. These areas involving
licensure and reimbursement are closely related. Regulations
concerning licensure of the unit are, in many ways, the legal
foundation on which reimbursement agreements are based. This
is particularly true when the reimbursement, or even a portion
of it, is derived from public sources, such as Medicare and
Medicaid. Organizations seeking to open subacute care units
should study these complex issues carefully, with the assistance
of well-qualified legal counsel, preferably with experience in
subacute care–related legal matters. Operators of nursing care
facilities who are thinking of getting into subacute care should
look carefully at several professional liability issues that may
be new to them, including malpractice, incident reporting
mechanisms, claims management, and credentialing of its
professional staff.
■ Management of Subacute Care Units
The program administrator, while responsible for administration
of the subacute care function, may fit into a variety of places
within the overall organization. If the subacute care unit is a
freestanding unit, functioning on its own, the administrator
probably reports to a governing board. If it is part of a hospital
or nursing facility organization, the subacute program
administrator probably reports to an administrator at a higher
level in the organizational hierarchy. The same holds true in a
multiorganizational integrated healthcare network.
It is important that the administrator have access to needed staff
and other resources to do the job effectively and successfully. If
subacute care is a new venture for the organization, the
administrator should be in place at the very beginning. He or
she should have responsibility for staffing and recruitment of
36. staff. The administrator (in any organizational setting) should
have confidence in his or her staff. The best way to do that is to
hire them. If a new facility is being built or if it requires major
renovation of an existing space, the administrator should also be
directly involved in that phase of development.
On an ongoing basis, the program administrator has overall
responsibility for ensuring the quality of care given; for the
effectiveness, efficiency, and productivity of staff; and for
planning future activities. Those responsibilities, particularly
ensuring the quality of care, may be met through the work of
others, but the administrator remains accountable for their
success. That requires a well-trained, skillful manager.
Management Qualifications
Subacute care administrators need the same skills as
administrators of other healthcare organizations. Administra tors
of nursing facilities must be licensed by the states, but hospital
administrators are not. With subacute care being so new and
being delivered in both types of facilities, what assurance is
there that the administrators are qualified? The American
College of Health Care Administrators developed a program to
certify subacute care administrators. That program, with its
study materials, provided both training of subacute care
administrators and documentation of their skills. It was a
voluntary certification, but it was eventually dropped because of
lack of interest by the professionals and lack of requirement for
it.
Management Challenges and Opportunities
There are many reasons for creating a subacute care unit or
facility. It provides an organization with many opportunities for
expanded services. It is a means of gaining or protecting a
market niche. Even if it only means finding new uses for
currently underutilized beds or facilities, subacute care has
much to recommend it. However, converting to subacute care
also presents some formidable challenges. Let us look briefly at
some of them.
Changing the Culture of the Organization
37. Any time an organization moves from one type of care to
another, there are likely to be some changes in its culture. Each
organization has its own culture based on a set of principles
and/or beliefs that determine acceptable behaviors. Subacute
care is just developing its own distinct culture, borrowing from
both hospitals and nursing facilities and their established
organizational cultures. Yet, either of those entities wishing to
move into the subacute care arena must make some fundamental
changes as well.
The dichotomy between nursing facilities and hospitals has been
described as care versus cure. Acute care hospitals are
accustomed to short lengths of stay, intensive medical and
nursing care, and high-technology equipment. They, of
necessity, place emphasis on curing the patient’s particular
malady.
Nursing care facilities, on the other hand, are used to caring for
their residents for long periods of time. They focus on the
overall person and that person’s quality of life. Even the names
given to these consumers of care reflect the differences. When
in a hospital, they are called patients. When in a nursing
facility, they are seen as residents.
Subacute care is more closely aligned with acute care. It
requires relatively high-technology equipment. Services are
aimed at treating a medical condition or functional limitation.
Lengths of stay are shorter than in nursing facilities but longer
than typical hospital lengths of stay. Required staffing patterns
are higher than in nursing facilities but lower than in hospitals,
both in terms of the staffing mix and the number of hours per
day allocated to each patient.
The culture change involved in moving into subacute care is
greater for nursing facilities than for hospitals. They must act
more like acute care, turning their energies and resources to
achieving short-term goals that center on improving a specific
condition, instead of focusing on longer term goals related to
the resident’s quality of life. They must change their staffing to
more closely reflect a medical model of care.
38. Hospitals moving to subacute care have to change their culture
as well. Lengths of stay are longer than those to which they
have been accustomed. They must adapt to lower staffing levels.
Patients in subacute care expect more amenities related to their
personal comfort. They are there longer, are usually not as ill as
when in an acute care setting, and expect their living quarters to
be more homelike.
These changes in organizational culture are not impossible to
achieve. Indeed, many subacute care units have successfully
been created out of both hospitals and nursing facilities. The
biggest obstacle to doing that is an organization’s inability or
unwillingness to recognize that there are differences. It is not
enough to simply change the name of a unit, transferring current
attitudes and activities, and hoping it will work. Getting all
staff, especially highly skilled physicians and nurses, to change
their fundamental way of functioning is a challenge for any
subacute care administrator.
Balancing Cost and Quality
It is a challenge for any healthcare organization to successfully
balance quality of services with cost-effectiveness. Subacute
care units are more focused on that than some other healthcare
entities. There are several reasons for that, not the least of
which is that subacute care came about largely as a means of
providing care at a lower cost than in acute hospitals. Had that
incentive not been present, it is doubtful that subacute care
would have developed as rapidly as it has, if at all.
As was noted earlier, managed care is a major influence on
subacute care. MCOs see subacute care as a viable alternative to
higher cost treatment in acute care hospitals. As their influence
on subacute care providers continues to grow, there is related
pressure on those facilities to slash their operating expenses.
With that cost-cutting effort comes a responsibility to ensure
the continued quality of care. MCOs will not continue to
contract with a subacute care provider, no matter how cost
effective, if that provider cannot assure a certain level of
quality. MCOs have more providers from which to choose; as
39. competition increases in the subacute care industry, so does the
need to develop meaningful measurements of facility quality.
Achieving success in both cost-effectiveness and quality is not
easy and presents an ongoing challenge for subacute care
providers.
Coordination and Competition With Other Facilities and
Organizations
Subacute care units have experienced, and can expect to
continue to experience, a considerable amount of competition as
others see the opportunities it presents. At the same time,
subacute care units must interact with other organizations if
they are to succeed. One of the challenges for any subacute care
organization is maintaining a balance between the two forces of
competition and cooperation. It must carefully analyze its
operating environment, watching for potential collaboration
opportunities as well as threats from competitors.
Subacute care is not an organizational entity that can stand on
its own well. It must have sources of patients. Few subacute
care patients are admitted without some prior admission to an
acute hospital or some contact with an MCO and its affiliated
hospital or medical staff. To succeed, the unit needs referral
agreements with other levels of care. It also needs discharge
opportunities for its patients.
Choosing those organizations with whom to associate and those
with whom to compete requires a sound analysis and evaluation
of the subacute care unit’s own capabilities, its strengths, and
its weaknesses, as well as the strengths and weaknesses of
potential competitors or collaborators. The subacute care
organization may not always have the option of choosing. Those
other organizations will be going through the same analysis and
evaluation process. The one that does so most effectively will
be in the best position to determine its own partnerships.
Subacute care units, even those that are physically freestanding,
tend to be affiliated with or owned and operated by hospitals or
nursing facilities. Within those parent organizations, there is
need to integrate the subacute services with others offered,
40. while maintaining the separateness that is required for
reimbursement and accreditation purposes. The physical plant,
staffing, administrative oversight, and policies and procedures
are all areas that should be addressed if that balance is to be
sustained.
Physical Facility Considerations
As we have noted, subacute care units are often carved out of
hospitals or nursing facilities. Neither of those facilities is ideal
for subacute care, although for hospitals, it primarily means
designating a section or a wing of the facility for subacute care.
It must be a dedicated unit, either a separate facility, standing
on its own, or, if part of a larger facility, physically separated
from other patient units.
The unit may already have the necessary technology available.
For nursing facilities, the magnitude of change is much greater.
They must usually do more and spend more to convert to this
different level of care. They should anticipate a significant
investment in unit renovation and capital equipment, as well as
in upgrading a variety of systems. They will probably have to
upgrade the unit, including such improvements as adding piped-
in oxygen, electric beds, and other equipment necessary for
providing a higher level of care. If rehabilitation services are
offered, there will likely be need for additional space for
physical and occupational therapies. If the services are
primarily medical, other clinical modifications will be needed.
A major change for many nursing facilities entering the
subacute care business is the need for a sophisticated
information system. Contracting with MCOs, documenting
treatments and costs, and maintaining a successful outcomes
measurement system require more data-handling capacity than
many nursing facilities have traditionally had. NCQA standards
require MCOs to practice utilization management. The MCOs,
in turn, pass those utilization management requirements on to
the providers with whom they contract. Nursing care facilities
with strong information systems are more likely to be
competitive for MCO contracts.
41. ■ Significant Trends and Their Impact on Subacute Care
Change is a given in any specialty care area as new and
relatively undefined as subacute care. Some change comes from
trends in overall health care, some from trends more specific to
long-term care, and some from trends within subacute care
itself. All have the potential for causing significant, and
sometimes dramatic, change within the subacute care field. We
have discussed some of those trends in our earlier discussions,
but let us summarize them briefly.
Managed Care
Clearly, the most important trend affecting subacute care is the
increased influence of managed care. It has been a primary
factor in the growth of subacute care to date and will continue
into the future. Pressures to provide quality care at low cost will
not diminish, further fueling the growth of managed care plans.
As public entities become more experienced at applying
managed care theories and practices to reducing their costs, the
demand for niche providers such as subacute care will continue
to expand.
That demand will encourage more and more organizations to try
their hand in the area of subacute care. Not all will succeed.
Some will fail because of poor planning, others because they
did not provide adequate resources. A few will fail in spite of
good planning and administration, simply because they are
outdone by a competitor. Eventually, the field will mature and
settle down some, but in the meantime there will be continued
turmoil caused by new entries into the field and the resultant
casualties.
Changes in Acuity Levels
As managed care and other cost-effectiveness measures
continue to seek the least expensive form of care, the acuity
level of patients in each type of provider will continue to rise,
as it has recently. That trend is supported by consumers’ desires
to receive care in the most homelike setting possible. The
impact on subacute care will be that patient treatments that,
today, are provided in hospitals will be handled in subacute care
42. units. That means that those units will require even more high-
technology capabilities. At the other end, nursing facilities will
be prepared for more of the treatments that are now commonly
performed in subacute care.
Emphasis on Outcomes
Payment sources for subacute care, particularly private MCOs,
will continue to emphasize outcomes as a basis for measuring
organizational performance. Those outcome measures will
contain both quality and cost-effectiveness components and will
require that the two be balanced. As Medicare and Medicaid
experiment more with managed care, it is likely that they will
adopt some of the outcomes measurement systems developed in
the private sector. Because they are also the primary regulators
of subacute care, that may lead them away from some of the
more intrusive forms of regulation, such as current survey
formats, toward more outcome-oriented regulations. This may
be simply wishful thinking, but there is some logic in seeing
that as a trend.
■ Summary
Subacute care is the fast-growing child of the healthcare
industry. Its clothes do not seem to fit. It is developing faster
than it can learn the rules by which it should play, and it keeps
experimenting with new and different ideas and approaches.
New playmates keep appearing on the scene. Its parents—
payers, regulators, and policy makers—are trying to keep up
with it and, like any parent, are trying to keep it from injuring
itself. However, they are finding it difficult to stay ahead of this
exciting, but sometimes unruly, child they have created.
Like most children, subacute care will develop into a useful,
productive adult of which its parents can be proud. The growth
years may be difficult, but the very fact that it is a new industry
segment and is ill defined and poorly regulated leaves room for
innovation and creativity. The competition from different
provider groups and from within those groups is already
resulting in some outstanding examples of good care and good
management.
43. Accrediting agencies such as the Joint Commission, CARF
International, and NCQA have moved with relative speed to
create standards for subacute care and are using measures based
primarily on outcomes, as opposed to structure and process
measures. Government regulators have not followed suit, at
least at this time. They will have to if subacute care is to
survive as a distinct and viable segment of the healthcare
continuum.
The past several years have been exciting and challenging for
all involved with subacute care. The next few years, as we move
toward and into the next millennium, promise no less.
Subacute Care Case
This case involves two people. Both have been admitted to
subacute care units following stays in an acute hospital.
However, they are different in many ways, as is the type of care
they receive. They are used here to demonstrate some of the
differences in the segment of the continuum known as subacute
care.
David is 17 years old. He was injured in an automobile accident
several months ago. Suffering multiple fractures and some
internal injuries, he has been in a hospital for several weeks.
While his initial injuries have largely healed, with the help of
several operations, he still faces a long, difficult period of
rehabilitation. It is for that rehabilitation, as well as monitoring
of his overall condition, that he has been transferred to a
subacute care unit.
Joyce is 67. She has a long history of heart trouble and was
admitted to the hospital following her last massive heart attack.
That attack, coming on top of her already weakened heart
condition, has left her in a semicomatose state. Her breathing is
assisted by a mechanical ventilator, and she must be fed and
medicated intravenously.
The subacute unit to which David was sent is known as a
general subacute unit. It is operated by, and in conjunction
with, a multilevel nursing facility. Joyce, on the other hand, was
admitted to a chronic subacute care unit, operated by the
44. hospital from which she was transferred. The difference
between the two units is primarily the conditions they mostly
treat and the kinds of staff and equipment needed to do what
they each do best.
Both of them began their journey through subacute care with an
assessment by multidisciplinary teams from the subacute units
to which they were being transferred. Those assessments
identified physical, medical, and mental conditions and
developed individual care plans designed to best achieve the
outcome goals identified for them. Because David appeared to
be in need of physical rehabilitation, his assessment team was
heavily weighted with therapists of one type or another, while
Joyce’s assessment team was much more nursing oriented.
David’s outcome goal is to be able to return to his home and
eventually back to school. The assessment team estimates that
he will regain nearly all if not all of his previous functional
independence. To achieve that, he requires intensive
rehabilitation, including physical and occupational therapy. His
care team is headed by a physiatrist and will focus on those
therapies, although his medical condition will be watched.
Joyce’s prognosis is not nearly as bright. The team assessing
her agreed that she is unlikely to ever improve and sets a goal
of maintaining her condition as well as possible until her death,
something that is not likely to be that far distant. She does not
need rehabilitation, although staff in the unit do some
maintenance range-of-motion exercises with her to keep her
physical condition from deteriorating. She does, however,
require much more intensive nursing care and monitoring than
does David and will be cared for under the watchful eye of a
cardiologist.
Another difference, based on expected outcomes, is that David
will receive close follow-up care after he is discharged to his
home. He will probably continue some of his therapy on an
outpatient basis and will be tested periodically to make sure he
has not regressed in his quest for functional independence.
Joyce, unfortunately, will not have that option.
45. While the probable results of their subacute care are expected to
be so different, Joyce and David have a common reason for
being transferred to those units. Their care needs are too high
for them to be treated at lower levels, such as nursing facilities
or at home. Yet, they do not need acute hospital care. A
secondary, but very important, factor contributing to those
transfers is the cost of care. David is covered by a managed care
plan to which his parents belong. Joyce is eligible for Medicare.
Both reimbursement sources want to give them the best care
they can, but at the lowest possible cost.
Thus, these two people in such different situations both find
themselves in subacute units, between hospital and nursing
facility care levels. It is a kind of care that suits them both well.
Until only a few years ago, David would have stayed in the
hospital for many months, at an unnecessarily high cost. Joyce
might have remained in the hospital also, but because she was
unconscious and was going to die anyway, it is more than likely
that she would have ended up in a nursing facility unprepared to
provide her with the care she should have had.
■ Vocabulary Terms
The following terms are included in this chapter. They are
important to the topics and issues discussed herein and should
become familiar to readers. Some of the terms are also found in
other chapters but may be used in different contexts. They may
not be fully defined herein. Thus, readers may wish to seek
other, supplementary definitions of them.
care management
care planning
CARF International
case management
case manager
certificate of need (CON)
chronic subacute care
continuous quality improvement
diagnosis-related groups
gatekeeper
46. general subacute care
interdisciplinary team
long-term transitional subacute care
managed care organizations (MCOs)
National Committee for Quality Assurance (NCQA)
quality assurance and performance improvement (QAPI)
skilled nursing facilities (SNFs)
subacute care
transitional subacute care
■ Discussion Questions
The following questions are presented to assist you in
understanding the material covered in this chapter. They tend to
be general but lend themselves to detailed answers. The answers
to these questions can be found in the chapter.
1. What are postacute and subacute care?
2. Where is subacute care provided, and by whom?
3. What types of services are included in subacute care?
4. How and why did subacute care develop?
5. How is subacute care financed?
6. What regulations apply to subacute care?
7. What is the difference between care management and case
management?
8. In reference to the case at the end of this chapter, consider
the following:
a. How can subacute care meet the needs of such different
patients as David and Joyce?
b. Should both be included in a single care category, or should
47. different levels of care be created for them?
c. Is subacute care really a response to patient needs, or is it a
way of increasing financing for providers?
NOTE: This question applies to the overall system, but applying
it to the case will assist you in seeing the implications for those
using the system.
■ References
AHA. (2014).
Rehabilitation. Retrieved from American Hospital
Association:
http://www.aha.org/advocacy-
issues/postacute/rehab/index.shtml.
American Hospital Association (AHA). (2010, June).
Maximizing the value of post-acute care. Retrieved
from
http://www.aha.org/research/reports/tw/10nov-tw-
postacute.pdf.
Anthem. (2013, May 9).
Inpatient subacute care. Retrieved from
http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a050
124.htm.
Buxbaum, R. (2009, March).
Subacute care: The road ahead. Retrieved from
http://www.annalsoflongtermcare.com/content/subacute-care-
the-road-ahead.
CA Subacute Care Unit. (2012).
Subacute care. Retrieved from
48. http://www.dhcs.ca.gov/provgovpart/Pages/SubacuteCare.aspx.
Centers for Medicare & Medicaid Services (CMS). (2012).
Post acute care reform plan. Washington, DC: Centers
for Medicare & Medicaid Services. Retrieved from
http://www.cms.gov/Medicare/Medicare-Fee-for-
Service-
Payment/SNFPPS/Downloads/pac_reform_plan_2006.pdf.
Centers for Medicare and Medicaid Services (CMS). (2013,
June 5).
QAPI description and background. Retrieved from
http://cms.gov/Medicare/Provider-Enrollment-and-
Certification/QAPI/qapidefinition.html.
Dummit, L. (2011, March 28).
Medicare’s bundling pilot: Including post-acute care
services. Retrieved from
http://www.nhpf.org/library/issue-
briefs/IB841_BundlingPostAcuteCare_03-28-11.pdf.
Griffin, K. (1995).
Handbook of Subacute Health Care. Gaithersburg, MD:
Aspen Publishers.
Hyatt, L., & Cornish, K. (1997). Regulations to watch for in
1997.
Journal of Long-Term Care Administration, pp. 21–23.
MedPac. (2013).
A data book: Healthcare spending and the Medicare
program, June 2005. Washington, DC: Centers for Medicare &
Medicaid Services.
ParentGiving. (2013).
What is subacute nursing home care? Retrieved from
49. http://www.parentgiving.com/elder-care/skilled-
nursing-facility-sub-acute/.
Singh, D. (2010).
Effective management of long-term care facilities (2nd
ed.). Sudbury, MA: Jones and Bartlett Learning.
Long-Term Care: Managing Across the Continuum, Fourth
Edition
John R. Pratt
CHAPTER FIVE: SUBACUTE AND POSTACUTE
CARECHAPTER HIGHLIGHTS
What is Postacute Care?
· Services to patients needing additional support to assist them
to recuperate following discharge from an acute hospital.
What is Subacute Care?
· Comprehensive, cost-effective inpatient level of care for
patients who have had an acute event.
What is the Difference between Postacute Care and Subacute
Care?
Subacute CarePost-Acute Care
- May be
either after or in place of acute care
- Is
after acute care
50. - Provides
in-patient services
- Provides
outpatient services
- Provides
medical and nursing care
- Provides
nursing and/or
non-medical care
Postacute Care
· Provided by:
· Inpatient Rehabilitation Facilities
· Long-Term Care Hospitals (LTCH)
· Skilled Nursing Facilities
· Home Health Agencies
· Use of Postacute Care
· About one-third of hospital patients go on to use postacute
care. The most common, single, postacute care destination for
beneficiaries discharged from acute inpatient care hospitals is a
skilled nursing facility.
· Medicare Conditions of Participation - providers must meet
different conditions of participation
· Bundled Payments - Like other Medicare-certified providers,
post-acute care providers will be impacted by CMS’s Bundled
Payments for Care Improvement initiative.
· Readmissions - The Affordable Care Act of 2010 (ACA)
reduces payments to hospitals for greater than expected
readmissions, decreasing payments for all Medicare discharges
in the prior year.
51. Subacute Care
How did Subacute Care come to be?
· It is one of the fastest growing segments of the health care
delivery system.
· Result of pressures to be cost-effective, increased demand for
consumer choice, and competition between providers.
Defining Subacute Care
· Comprehensive inpatient care designed for someone who has
an acute illness, injury, or exacerbation of a disease process.
· Goal oriented treatment rendered immediately after, or instead
of, acute hospitalization to treat one or more specific active
complex medical conditions or to administer one or more
technically complex treatments.
Philosophy of Care
· Specific care rendered for very specific reasons (conditions or
treatments)
Ownership of Subacute Care Units
· Often provided by existing hospitals or free-standing nursing
facilities.
Services Provided
· May include:
· Rehabilitation
· Physical and Occupational Therapy
· Respiratory Therapy
· Cardiac Rehabilitation
52. · Speech Therapy
· Postsurgical Care
· Chemotherapy
· Total Parenteral Nutrition
· Dialysis
· Pain Management
· Complex Medical Care
· Wound Management
· Ventilation Care
· Other Specialty Care
Care Planning
· Involves assessing each individual patient's needs, developing
a care plan to meet those needs, and constantly reviewing the
care plan and adjusting it as needed.
Measuring Quality of Care
· There are numerous excellent tools available for measur ing
outcomes-based effectiveness.
· QAPI is the merger of two complementary approaches to
quality, Quality Assurance (QA) and Performance Improvement
(PI). Both involve seeking and using information, but they
differ in key ways
Case Management
· Its primary goal is the cost-effectiveness of the care given.
Consumers Served
53. · Patients needing a high level of skilled care, generally with a
defined treatment plan and timetable for discharge or transfer to
another type of care.
· They need rehabilitation, monitoring, or other specialized
treatment.
Market Forces Impacting Subacute Care
· Cost Saving Efforts – the primary impetus for subacute care.
· Managed Care – A key promoter of subacute care.
· Choice - The rising demand by health care consumers for more
choice in their care is important.
Regulations
· Subject to most of the same regulations as other providers, but
is still an immature provider form.
Accreditation
· Joint Commission – Joint Commission on Accreditation of
Healthcare Organizations
· CARF International – Commission on Accreditation of
Rehabilitation Facilities
· NCQA – National Committee on Quality Assurance
Financing Subacute Care
· No single payer for subacute services, nor any standardized
payment mechanism.
· Most reimbursement comes from Medicare, Medicaid, and
managed care organizations.
· Managed care influence is growing, even for public payers.
Staffing/Human Resource Issues
· Interdisciplinary team consisting of:
· Program Administrator
54. · Physicians
· Nursing
· Other Professional Staff
· Non-Licensed Staff
· Recruitment
Legal/Ethical Issues· Fall into two general categories:
· Meeting licensure and reimbursement regulations
· Professional liability
Management
Management Qualifications· Subacute care administrators need
the same skills as administrators of other health care
organizations.
Management Challenges and Opportunities
· Changing the Culture of the Organization – may be part of a
hospital or skilled nursing facility with different culture
· Balancing Cost and Quality – similar to other providers.
· Coordination, Competition with Other Facilities,
Organizations – need to work with others to survive.
· Physical Facility Considerations – may have to adapt from
another provider type.
Significant Trends and Their Impact on Subacute Care
· Managed Care – a growing influence.
· Changes in Acuity Levels – accepting patients from acute care
– or instead of acute care presents certain problems.