ICU to Long-Term Acute Care Hospital (LTACH), Strategies for Smarter Care Transitions

Summary

---

Becker’s Healthcare Podcast Summary

Episode Title: ICU to Long-Term Acute Care Hospital (LTACH): Strategies for Smarter Care Transitions
Date: October 21, 2025
Host: Lucas Voss (A)
Guest: Mike Fancher, Division Vice President, Kindred Hospitals Coastal Region (B)

---

Overview

This episode explores the evolving challenges and strategic approaches to transitioning patients from the Intensive Care Unit (ICU) to Long-Term Acute Care Hospitals (LTACHs). The conversation centers on compounding resource constraints, inefficiencies in existing processes, and practical strategies for smarter care transitions and improved patient outcomes through collaboration, process redesign, and early intervention.

---

Key Discussion Points & Insights

1. Current State: Compounding Constraints in Healthcare

• Persistently High Hospital Capacity:
  • Many hospitals, especially ICUs, are operating above 70% capacity since 2023, leading to systemic strain.
• The Nature of Compounding Constraints:
  • Constraints are interconnected, and resolving one often exacerbates others.
  • Example: Creating ICU step-down units merely shifts longer patient stays and cost burdens from one area to another, not solving the root issue.
• Nursing Shortage Compounder:
  • Specializing ICUs (medical, cardiac, neuro, trauma) increases staffing complexity in a time of rampant nursing shortages.
• Market Pressures:
  • Closures in major cities (e.g., Philadelphia lost 9 hospitals in ~6 years), escalating pressure on remaining hospitals.
  • Quote:

    "Each one of those keeps compounding upon the other and it just creates an array of constraints that makes it very difficult to continue to function." — Mike Fancher [03:44]

2. Finding the Right Balance

• Feedback Loops Lead to Bottlenecks:
  • Reduced staffing slows discharges, increasing lengths of stay, which bottlenecks patient throughput and increases staff burnout.
  • Integrated Perspective Needed:
    • Siloed thinking (e.g., only optimizing ED flow without addressing discharge bottlenecks) perpetuates systemic drag.
  • Reference to 'The Goal' (Dr. Eli Goldratt):
    • Applying the "theory of constraints" can reveal and address true system bottlenecks.
• Early and Realistic Discharge Planning:
  • Discharge goals set too early or based on outdated assumptions (e.g., automatic return to nursing home) can hinder proper placement and care.

3. Smarter Strategies for ICU–LTACH Transitions

• Shift from Policy/Procedure to Process-Focused Solutions:
  • Process-driven approaches (often enabled by technology) outperform traditional policies or procedures.
• Standardized, Early Screening for LTACH Candidacy:
  • Initiate consideration for LTACH transfer within the first 96 hours of ICU admission rather than waiting for 25+ days.
    • Quote:

      "We started the process earlier, actually at the 96 hour point...Referrals or early looks were actually being made at these patients." — Mike Fancher [10:36]

• Ownership and Accountability:
  • Determining who initiates post-acute care referrals is often ambiguous; the best process assigns clear roles and triggers, reducing dependency on constant re-education.
• Addressing Staff Turnover:
  • High churn among case managers complicates education efforts — better processes can reduce the need for repetitive training.
    • Quote:

      "How do you educate without educating? ...the answer is you develop a process that removes the need or the requirement for that education component." — Mike Fancher [10:26]

4. Critical Role of Coordination and Transparency

• Cross-Provider & Payer Collaboration:
  • True throughput improvement requires close coordination across health systems, LTACHs, and payers—with shared goals and incentives.
  • Transparency is Lacking:
    • Barriers arise when payers (especially Medicare Advantage) have inconsistent or opaque authorization processes, creating delays or denials unrelated to clinical status.
    • Quote:

      "There has to be transparency, and that's just gonna have to be an agreement that really starts to occur... When that happens, you're going to see a drastic increase in throughput." — Mike Fancher [13:25]

• Lessons from COVID-19:
  • Temporary policy changes (relaxed authorization requirements) enabled unprecedented throughput, proving rapid transition is possible under aligned incentives.

5. Mindset and Systemic Change

• Holistic View of Throughput:
  • Throughput issues are not confined to single hospitals or systems; they require integrating post-acute providers as full partners in the care continuum.
  • Unified Approach:
    • Best results emerge when payers are seen as partners, not adversaries, and all stakeholders operate with shared transparency and aligned process flows.
    • Quote:

      "Throughput itself is not a system problem. It's not a single hospital problem. The best systems... are treating post acute partners as an extension of their own care continuum." — Mike Fancher [15:25]

---

Memorable Quotes

• On capacity and constraints:

  "Each one of those keeps compounding upon the other and it just creates an array of constraints that makes it very difficult to continue to function." — Mike Fancher [03:44]

• On process vs. policy:

  "Process, for the most part, beats policy and procedure every single time when the process is valid." — Mike Fancher [08:11]

• On the importance of early, process-driven LTACH referral:

  "Instead of everyone guessing on day 25 or day 27 that a patient may or may not be appropriate for LTACH, we started the process earlier, actually at the 96 hour point." — Mike Fancher [10:36]

• On transparency and the payer-provider relationship:

  "There has to be transparency, and that's just gonna have to be an agreement that really starts to occur... When that happens, you're going to see a drastic increase in throughput." — Mike Fancher [13:25]

• On systemic, not siloed, solutions:

  "Throughput itself is not a system problem. It's not a single hospital problem... The sooner that we can get to a point where the outside and the inside of our hospital systems are working together with that transparency, with the payers by our side, not across the table, that is where we're really gonna see the success that we wanna see." — Mike Fancher [15:25]

---

Key Timestamps

• 00:37—02:00: Mike Fancher’s background and early industry perspectives
• 02:00—04:24: The compounding constraints challenging ICUs and hospital flow
• 04:24—07:43: How feedback loops and poor discharge planning perpetuate bottlenecks
• 08:02—11:49: Moving to process-focused strategies; early identification for LTACH needs; dealing with case manager turnover
• 12:23—14:55: The necessity of payer-provider transparency and collaborative partnerships for throughput
• 15:11—16:02: Final thoughts on holistic, cross-continuum collaboration as the path forward

---

Takeaways

• Proactive, process-driven approaches (such as early and standardized screening for LTACH candidates) can resolve many throughput issues without the need for endless retraining or policy changes.
• Transparency, especially with payers, is the missing link to unlocking system-wide efficiency gains.
• Holistic, cross-functional collaboration (hospitals, post-acute providers, payers) is vital—success requires breaking down silos and aligning incentives across all levels.
• Throughput challenges are systemic and require both a mindset and an operational shift—seeing post-acute partners as essential extensions of hospital care.

---

Transcript

[A]

Hi everyone, this is Lucas Voss with Becker's Healthcare. Thanks so much for tuning in to the Becker's Healthcare podcast series. Fantastic to have you. Today we're going to talk about ICU to long term Acute care hospital, or LTCH as we refer to it, strategies for smarter care transitions. And joining me for today's discussion, very excited to have him, Mike Fancher, division vice president for Kindred Hospital's coastal region. Mike, thanks so much for being here today. It's great to have you.

[B]

Well, thanks so much for having me. Very excited for this conversation.

[A]

Absolutely. For our audience, could you just introduce yourself, tell us a little bit about your work and your time in healthcare.

[B]

Sure. I never imagined that I'd be in the healthcare world. I first dipped my toe into the world of LTAC nearly 18 years ago, so a very long time. I had spent about a decade in the financial industry prior to that. So I don't have a clinical background, which in many ways allows me to look at things from a slightly different viewpoint. And in working with so many different hospitals, especially now across the coastal region, I realized how much each hospital really is just like an individual person. They're their own individual organization and their needs, their requirements, what they're looking for, tend to be very specific to them. However, there are also global things that are definitely impacting hospitals and the healthcare industry as a toll that we're able to really dive in and help hospitals achieve what they need to do.

[A]

Yeah, and we'll talk about some of these factors here in a little bit because again, they are very wide spanning and there are a lot of issues and one of them is right, we've, we've identified that hospital back capacity has, has really remained elevated, consistently sitting above 70% since 2023. Very significant. Especially ICU capacity limits and patient flow are really causing that strain for four systems. From your perspective, what are some of the biggest factors driving those pressures today?

[B]

I think the biggest concern with the specific issues is that they're not specific and they're not individualized. They're actually, we commonly call them compounding constraints, which kind of refers to the cumulative effect of multiple limitations that really interact and wind up amplifying each other over time. And this overall, it just reduces organizational flexibility, efficiency, performance. Unlike isolated problems, compounding constraints, they're very interconnected and each one of them can be their own bottleneck. What's unique about the healthcare industry right now, specifically when it comes to, you know, ICUs that are being, they're just under capacity in most cases, you have Long wait lines and EDs, and a lot of that does stem from the ICU over capacities. When you run into those issues, each one of them becomes a bottleneck. But, but the solutions that hospitals used to use to deal with some of those bottlenecks are now actually compounding the problem. So for an example, in the past when an ICU was full, the next step to do was to create an ICU step down, which sounded great. However, now that they've done that, they're just continuing that length of stay and they're just moving the problem of length of stay, avoidable costs, all of those things from one floor to the other. Then the next step was, well, you know what? We're going to start differentiating our ICUs. So now you have medical ICUs, cardiac, neuro, trauma, all of those things, which is great and it allows for specialized care. However, when you have a shortage of nurses across the country, now you're compounding because now you have those high acuity nursing ratios that are required in each one of those units. But we have a shortage of nursing. So we keep creating. Each one of those creates a problem. One of the biggest things probably is that you've seen it. We have hospitals across the country right now that are closing. And I can use Philadelphia as an example right now, as it's in the east coast of the United States. In just a matter of about four to six years, they've lost nine hospitals in the Philadelphia market, two of them alone in the last four months. And that is just putting added strains. So each one of those keeps compounding upon the other and it just creates an array of constraints that makes it very difficult to continue to function.

[A]

Yeah. And one of the key pieces, you've mentioned the compounding piece a couple of times, and that's so, so, so important because now we have these multiple factors that are all sort of snowballing, as you've mentioned. And one key thing is in that is balance, you have to find balance. Right. So I just wanted to come back to that. Right. How can organizations balance critical care demand, which is clearly there, as we know, with those available resources that might not be there. What does that balance look like?

[B]

I think the first thing you have to identify is what the feedback loop is. So the feedback loop is that you go from limited staffing to now, you're slowing your discharges. When you have slower discharges, you're increasing your length of stay. When you have reduced capacity, that creates an additional problem. Then you have the boarding in the er, which creates a problem. Now you're leading to patient dissatisfaction, then burnout. Now you have even fewer staff. So the first thing you have to do is really identify that feedback loop and realize that they're not operating in silos. They are very, very interconnected. Once you start to realize where the initial bottleneck is and actually, I don't know if you've ever read it, one of my favorite books is called the goal. It's by Dr. Eli Goldratt and it really helps to identify and break down the theory of constraints. That's something that hospitals need to do. But instead of working in silos where you're looking at the admissions side and saying, how can we get more patients through the ED faster without looking at the discharge side of the icu? You're just, you're not taking the steps forward that you need to take. That whole problem, it creates that, you know, systemic drag essentially that every constraint winds up fueling the next. They have to be able to identify those. Once they do, hospitals need to be able to, how do I say, look at the overall system as a whole. But they have to start being proactive instead of reactive. This is one of the biggest issues. And you know, in 18 years of doing this, some of the issues haven't changed. Actually in 18 years they've gotten worse. So they've compounded, but the initial issues haven't changed. A great example is you have a patient that's been in icu, they are clinically complex, maybe they're on a ventilator, they're on dialysis, they have multiple comorbidities going on and oftentimes no one's thinking about discharge until that patient hits that 25 to 30 day length of stay. Stay in an ICU, which is crushing for an ICU. Part of the issue is that upon admission, let's say that patient actually came in from a nursing home per se, they got pneumonia, wound up septic, and suddenly they went into multi organ failure. So now they're that vented patient on dialysis in an icu. What's interesting is that on the admission records of that and in the first probably five days, the discharge or expected discharge disposition of that patient is return to nursing home, although that patient is in no state whatsoever to even think about that. However, when that is the goal, everyone is now leading themselves as to even pt. How do I work this patient to get them back to a nursing home even though they're not anywhere near ready for that status? So you have to think about, we have the right patient in the right time and going to the right place at a very early on stage.

[A]

Yeah. And again, you mentioned the elimination of silos. Right. And the integration piece, which are so crucial in enabling that process. Are there any other strategies that you can point to in improving throughput for folks? What are some of those strategies that. Or other strategies that you think are effective in improving that exact process that you just outlined?

[B]

So one of the things that I think is really important is hospitals move away from procedure and move away from policy and start looking at process. Everything today, look, we're in an AI world, right? So everything today is very driven by process. And process, for the most part, beats policy and procedure every single time when the process is valid. An interesting example I can give probably about five years ago, I was working very closely with an ICU medical director, and they were struggling in their ICU to really improve throughput. Their avoidable day costs were through the roof. Their length of stay was through the roof. Even their mortality was through the roof. They were seeing an increase in hospital acquired pressure, ulcers, hospital acquired infections. And he knew that they needed to utilize ltch better. His question really was how? And one of the ways he did this, and I remember when he first approached me, I was actually a little taken aback because he said, you know, Mike, we're not using ltch correctly. And I said, well, honestly, nobody is. And the reason why for that is there's a lot of different players that are involved. You have social workers, case managers, doctors, you have physicians, you have specialists, you have residents and fellows. In many teaching hospitals, there's a lot of different people that are looking at that patient and trying to manage the throughput of that. I said, although you would think with everyone combined, it actually gets better. Usually it gets more complicated. And he said, well, you're correct. And he goes, and that's the problem when it comes to ltch, we just don't understand the criteria. He goes, and quite honestly, Mike, you've been educating here for a long time, but you can't educate fast enough. And at first when he said that, I was a little like, wow, did we really just go there?

[A]

Maybe I am fast, right?

[B]

But I knew exactly what he meant. Because while we have shortages in staffing today, the other side that we don't tend to talk about is the turnover, right? Case management is such an important division of a hospital, and it has one of the highest areas of turnover in the hospital. So for us to constantly go in and try to explain what ltch criteria is on a daily basis almost, it Felt like by the time you finally got someone educated, they were now gone and someone else was coming into the role. So the question became, how do you educate without educating? And the answer is you don't. Actually. The answer is you develop a process that removes the need or the requirement for that education component. And you can do this in acute rehab, you can do this in subacute in all those different levels. What we wound up actually creating was a system where instead of everyone guessing on day 25 or day 27 that a patient may or may not be appropriate for ltch, we started the process earlier, actually at the 96 hour point. And within 96 hours, referrals or early looks were actually being made at these patients saying, does this patient look like it's going to have the potential to be ltch? They're not ready at that point for discharge. They're only 96 hours in. And we totally understand that. But instead of after 96 hours saying, the discharge's expected disposition is to go back to nursing home, now there's a different disposition. Now it's okay. This one may actually be appropriate and require that extended high level critical care need for an extended amount of time. When you start that process sooner, it allows for everyone involved instead of saying, well, we don't know if this one is or isn't ltch. And it also removes the responsibility factor. Case managers have to work with physicians and there's an eternal question of who actually initiates the referral, right? Is it the physician, Is it the case manager, Is it the social worker? In the end, it's everybody. When it's everybody, it's no one, Right?

[A]

It comes back to the proactive approach that you've mentioned. You have to be proactive in explaining to people that are. Everybody knows what they're doing at every point in time. It's a proactive approach ahead of time. I think that's so.

[B]

Exactly.

[A]

And one of the things, I just want to come back to this because I think it's very important. You mentioned you touched on the coordination piece, right? And sort of it goes back to what we talked about earlier with the compounding factors in all of this. How does that closer coordination between hospitals, ltchs, payers, all of this then improve both outcomes and efficiency that you've just touched on.

[B]

So that coordination, and really it's a collaboration, right. Is more important than ever. There's something that is missing in health care today. And it's a word. I mean, we hear it in politics, we hear it in so many words. The word is transparency. So where we get stuck is that clinically a patient can meet criteria specifically for ltch or even for acute rehab or other levels of care. Where we get in trouble is when an ltch says this patient meets clinical criteria and if the patient had a traditional Medicare would come right in. However, when you bring in the Medicare Advantage plans, it becomes a little bit more difficult. Now you have an approval process which not only slows it down, but in many cases it stops that process. You know, over 50% of all billable days today in hospitals, approximately over 50% are a Medicare Advantage type plan. So when you're looking at that situation, it's developing into a, either a stopgate, right? Either it's a go, no go situation. But that doesn't solve the throughput issue, it doesn't solve the avoidable day cost issue, all of those other issues. And the reason why is that there's truly there, there's a, a vague transparency. So I can have two patients that are identical, every single thing about them is the same and they actually have the exact same insurance and one of them gets approved and one of them does not. Why is that? What is it? Outside of this patient's either clinically unstable, but yet two days later they are so stable they can go to another level of care, which they can't. They still remain in that hospital for an extended amount of time. There has to be transparency, and that's just gonna have to be an agreement that really starts to occur. And where I think that's going to come from is post acute providers like ltchs and Primary Healthcare Systems are going to have to partner together to be able to really push for and ask for this transparency from the managed care side. When that happens, you're going to see a drastic increase in throughput. And the proof of that is Covid, right when Covid occurred. As much as nobody ever wants to go back to that horrible situation all over again, when you removed those authorization requirements, there was throughput. Even under the most massive strain we've seen in our healthcare systems for quite some time. We have an, we had an incredible amount of throughput. So that throughput is possible, but that transparency has to be there.

[A]

Yeah, absolutely. Well, with full transparency. Mike, what great insights. Thank you so much for being here. This is fantastic. Is there anything else that you want to share that we might have not touched on or that you think our audience would benefit from that we didn't talk about?

[B]

You know, I, as I coach employees throughout my time as, as a leader in health care. One of the things I always say is that if you wanna change the world around you, it does start by changing the world inside of you. Right. As an individual. But I'm gonna flip that around a little bit. When it comes to our healthcare system, Throughput itself is not a system problem. It's not a single hospital problem. The best systems that work really well are treating post acute partners as an extension of their own care continuum. And the sooner that we can get to a point where the outside and the inside of our hospital systems are working together with that trans. With the payers by our side, not across the table, that is where we're really gonna see the success that we wanna see. We're not just managing patients anymore. We have to be able to work through that process flow.

[A]

Yeah. Comes back to the proactive, holistic approach to the issue itself, which is so key. Mike, thanks so much for taking the time. It's great to have you.

[B]

Thanks so much for having me. Have a great day.

[A]

Absolutely. We also want to thank our podcast sponsor, Scion Health. You can tune into more podcasts from Becker's Healthcare by visiting our podcast page at Becker's Hospital Review.