The Continuum of Care

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The Continuum of Care

• Chapter 13, 14, 15, 16 17
• Tracey Lynn Koehlmoos, PhD, MHA

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Continuum of Care

• Prenatal Care/Healthy Birth
• Health Promotion
• Primary Disease Prevention
• Diagnosis of Disease
• Treatment of Acute Disease
• Secondary Disease Prevention
• Tertiary Disease Prevention
• Treatment of Chronic Illness
• Rehabilitative Care
• Long Term Care
• Palliative Care

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Primary Care

• Diagnosis of illness, initial treatment
• Episodic care for common illness injury
• Prescription drugs for common illness
• Routine dental care (exams, cavities)
• Diagnosis of potentially serious physical or
  mental health conditions that require prompt
  referral for secondary or tertiary care

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Primary Care Providersby Specialty
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Other Primary Care Providers

• More than 23 of clinical PC visits are to FPs
• PAs, ARNPs, Midwives, nurses, Chiropractors

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Issues in Primary Care

• Access
• Availability of providers
• 21 Specialists to PCPs
• Reimbursement
• Lower rate
• Devaluing of care
• Self-referral to specialists

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Secondary Care

• Disease has crossed the clinical threshold
• Continuing care of chronic conditions
• In-patient, ambulatory, specialty surgery center,
  hospital ER

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Ambulatory Visits by Physician Type
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Access to Secondary Care

• Financial barriers (frequent treatment)
• 99 Million Americans have chronic disease and
  that number is growing!
• By 2050, 167 million costing 906 billion
• Secondary care also includes hospitalizations
  with fairly common surgeries (hysterectomy,
  cardiac cath, childbirth)

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Issues in Secondary Care

• Growing need
• Limited access (financial, geographic, insurance)
• Many diagnostic and treatment services are
  moving/have moved to outpatient setting. (Shift
  in delivery system)

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Long Term Care

• Continuous care over a period of at least 90 days
  for acute and chronic conditions
• gt12 million need LTC in US population
• 50 lt65 yrs. (40 working adults, 3 kids)
• Includes mental and developmental disabilities
• Two measures
• ADLs Activities of Daily Living (basic tasks)
• IADLs Instrumental Activities of Daily Living
  (more complex social tasks, household chores)

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Need for LTC

• Expected to increase over 30 years
• Baby Boomers
• Life saving medical advances
• Low Birth Weight babies
• Accident and injury victims
• Congenital and Disabling conditions
• (Cystic Fibrosis, Polio/Post-Polio)

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Long Term Care Providers

• Informal7 million unpaid caregivers in US
• 75 women, 35 older 10 left employment
• 33 poor health 80 give 4 hours or more daily
• FormalMajority LTC is non-clinical
• Home health aid, visiting nurse, social worker
• Adult Daycare Provider, OT, PT, Speech Ther.
• Assisted Living, nursing home, shelter, senior
  centers

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Home Health Care

• Majority of HHC is for LTC unrelated to a
  hospitalization
• 25 of HHC agencies are hospital based
• Geographic variation
• Increased access via Medicaid Home and Community
  Based Services Waiver program (OBRA 1981)

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Nursing Home Care

• Residential population, 1.6 million
• Majority are elderly patients
• Some 2 million stay-and-go each year
• Various classifications (SNF, Rehab, Assisted
  Living) various reimbursement schemes
• Most nursing homes and ALF are privately owned

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Intermediate Care Facilities

• Developmental disabilities (mental retardation)
• ICFMR since 1971 (now, gt5000)
• Nursing, social, therapeutic services
• about 160K enrollees, majority adults
• Highest per capita expenditure of Medicaid
• 75,254 for 1998
• About 6.7 of all Medicaid expenditures

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LTC focusing on Elderly

• PACE/SHMOs community based to monitor
  potentially frail elderly for nursing home
  (PACElow income)
• Pooling of social and health services
• Avoid hospitalization/institutionalization
• Medicare, Medicaid funding (some beneficiary
  funding for SHMOs)

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LTC Financing

• Medicare 10 of all Nursing Home care
• Medicaid About 50 of Nursing Home care
• Spend downelderly patients resources get
  depleted during nursing home care
• Monthly charges for NH 3,900 (2002)

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LTC Summary

• Some 12 million Americans require LTC services
  (many face financial barriers)
• What part of health service system should be
  responsible for providing and paying for LTC?
• Increasing need, no public policy reform in place

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Tertiary Care

• Highly specialized, procedurally intensive
  inpatient care that may require a prolonged LOS.
  
• Examples
• CABGs, Joint replacement
• Quaternary care (new term)
• Academic Health Centers
• Burn Unit, Regional Trauma Center, Transplant
  Services, NICU

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Providers

• Specialist and sub-specialist who focus on one
  system, one organ, one disease
• Academic Health Center
• Highest level of care, largest uncompensated care
  (44 of all uncompensated care)
• Major training site of physicians
• Lots of public funding
• Admit high numbers of indigent patients
• All undergrad, 60 Grad medical education
• Research, research, research

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AHC Issues

• Higher Cost
• Increasingly competitive market from other
  specialty hospitals
• The ACH is the hallmark of US care unlikely to
  change

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Palliative Care

• Palliative/Hospice Care Care provided to ease
  the pain and stress of a terminal condition when
  no other medical or surgical intervention is
  available.
• Includes home health, freestanding hospice
  center, prescription drugs, counseling, social
  services, therapy
• Access requires physician certification of life
  expectancy lt 6 months

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Hospices

• About 3,200 in US (2002)
• 72 Not-for-Profit
• Medicare is largest payer (5,185 per capita)
• 19 lt65 years 27 gt85 years
• Median time in Hospice care 36 days
• Survival time is related to illness

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Appropriate Use and Other Issues

• Impossible to accurately predict point of death
• Futile Care technological advances allow us to
  prolong life
• Lack of health insurance can bar access
• Can be misapplied when there is no hope
• Physician Assisted Suicide
• Supreme Court 1997No right to PAS
• Oregon Death with Dignity Act (1994)

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Palliative Care Summary

• Combines all services for end of life care
• Medicare pays for 80 of Hospice care
• More aged citizens, more need for palliative care
• Other end of life issues arise in any discussion
  of palliative care

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Continuum of Care Summary

• Continuum starts with prenatal care and healthy
  birth and ends with Palliative Care
• It is possible to enter the continuum at any of
  the many steps depending on the illness or cause
  of injury
• Many people are denied access to any step in the
  continuum because of financial constraints.