← Becker’s Healthcare Podcast
Becker’s Healthcare Podcast
The Role of Long-Term Acute Care Hospitals and Partnerships in High-Acuity Care
00:17:10
Loading summary
Transcript19 lines
- [00:00]
A
Hello everyone. This is Erica Spicer Mason with Becker's Healthcare. Thank you so much for tuning in to the Becker's Healthcare podcast series. So today we're going to talk about the role of long term acute care hospitals and partnerships in high acuity care. And joining me for this conversation is Dr. Daniel Delportal, Senior Vice president and Chief Clinical Officer at Temple Health. Dr. Delportal, it's great to have you on the podcast today. Thank you so much for being here.
- [00:26]
B
Yeah, thanks so much for having me on the program.
- [00:29]
A
Really excited to have you. And before we get into our conversation, I wanted to give you the chance to share just a little bit more about yourself and your work in healthcare.
- [00:37]
B
Sure, thanks. So my clinical background is as an emergency physician. I'm a practicing ER doctor. I've been a medical staff leader, having served as president of the medical staff for our hospital and am now a clinical executive leader as the chief clinical officer of Temple Health, which is an an academic health system, encompasses both academic and community hospitals. We've got six hospitals, including our urban Safety net hospital, which is a level one trauma accredited burn center transplant center. We've got an NCI designated cancer center, a behavioral health hospital, and a large primary and specialty care network. I specialize really in clinical operations. So that includes optimizing capacity, access to care, efficiency of care delivery, timely progression of clinical care, and then really focusing on the transitions in and out of inpatient care. So whether it's through the front door of the emergency department or on the back end, linking patients from inpatient care to a post acute network of skilled nursing, acute rehab, and this interesting part of the continuum of care that we're going to be talking about today, which is the long term acute Care Hospital or LTCH.
- [01:51]
A
Yeah. Well, it's great to learn more about you, Dr. Del Portal. Thank you so much for the overview. And it sounds like you're wearing a lot of hats in your role. And I'm eager to hear kind of the role that long term acute care is playing at Temple. And so I'd like to start there. You know, when we think about long term acute care hospitals, or ltchs, as many people call them, and the role that they play in the broader continuum of care, how does that align with the needs of the patients that you're serving at Temple?
- [02:19]
B
Yeah, it's really about what each setting of care is designed to address. So short term acute care hospitals, what most people think of as their local hospital, where they'd go to the ER if they got sick, they're the right setting when there's a need to establish a diagnosis and treatment plan for emergency care, for, you know, a multi specialty consultation to establish a diagnosis and treatment plan or for most surgical procedures. By contrast, long term acute care hospitals, ltch really specialize in the care of patients with serious medical conditions that are going to require extended hospital level care. Usually it's more than 25 days. The average length of admission at an ltch is going to be much longer weeks to months than a short term acute care hospital which typically has an average length of stay of a week or less for the majority of its patients. So the model in many markets without ltchs is that a patient who needs hospital level care will stay in a short term acute care hospital until that patient's ready to be discharged to home to acute rehab, to a skilled nursing facility. For the more medically complex patients, that can be a really big transition and it can prolong their stay in the short term acute care hospital. Oftentimes that care can be delivered in other settings that are specifically designed for it, like ventilator weaning, tracheostomy care, intensive respiratory care, situations where there really isn't diagnostic uncertainty, but where the progression to rehab or home is going to be slow.
- [03:48]
A
That's super helpful to know, Dr. Delportal. Thank you. And so from what you're describing, it sounds like some organizations, they can make the short term care work if they don't have an ltch, but I'm sure that there's more to it than that. So if short term care can provide the level of care that you're describing, can you just say a little bit more about where and how ltchs are adding value?
- [04:12]
B
Yeah, absolutely. So, so keeping patients in short term acute care hospitals longer to meet those milestones, it's going to create a few problems. The first is access to inpatient care. We know that inpatient capacity at short term acute care hospitals is strained nationally. Right. So hospital closures, including in the area where I work in Philadelphia, are reducing the number of available inpatient beds. Some community hospitals are trimming services or even going to micro hospital models and sending more patients, referring them out to tertiary care centers. And that exacerbates that supply and demand mismatch for the inpatient beds. And that all leads to prolonged boarding of admitted patients in emergency departments for hours, sometimes days. And that's a national crisis that's, that's well described. It strains emerg care resources and it makes it really challenging for hospitals to provide stabilizing care to new arrivals, while also continuing to manage dozens of admitted patients. So the longer patients with medical complexity stay in short term acute care hospitals, the more the community can struggle to access inpatient services they need. The second problem with keeping medically complex patients longer in a traditional short term acute care hospital, for example, to wean from a ventilator, which can take weeks or months, is that it threatens the financial stability of short term acute care hospitals. And that's based on the way that hospitals are paid. The diagnosis related group or DRG payments to short term acute care hospitals are based on a geometric mean length of stay. That's a formula that minimizes the impact of the outlier cases. And hospitals will get paid a fixed rate by Medicare managed care commercial insurance plans for the typical duration and expenses of caring for most patients with that same diagnosis. So under a DRG based payment model, hospitals aren't really reimbursed in a way that covers the expenses of caring for the more medically complex patients. And it's not hard to see how that's gonna create a cycle right under reimbursement for longer stay patients hastens hospital closures, which strains regional bed capacity like I just mentioned. And finally, and I'd argue most importantly from the perspective of the patient, is that in areas without an ltch level of care, or for patients who don't have it as a covered benefit in their insur plan, they can get trapped, for lack of a better word, in the short term acute care hospital, which again is designed perfectly for stabilization, making a diagnosis, coordinating multi specialty treatment plans. But ltch by contrast, is designed specifically to provide the ongoing care, the ventilator, weaning respiratory treatment, nutritional support, pulmonary rehab, without competing for resources and time with those unstable emergency patients that are always arriving 24, 7, 365 days a year at the short term acute care hospital. So by moving to a setting that's designed to focus on the longer term, sometimes slower aspects of recovery, the patient can often have a better experience than if the short term hospitalization was prolonged for months and months. So I'd say that really ltch serve as a bridge between the short term acute care hospitalization and rehabilitation or home or a skilled nursing level of care that really aren't equipped to handle the medical complexity of the patients we're talking about. We've sent a broad variety of patients to ltch, from trauma patients to those with severe pulmonary disease and ventilator dependent respiratory failure, those that are slow to wean off of ventilators, to those requiring longer courses of antibiotics for infections, but that have significant active comorbid illness that can't really be well controlled in a non hospital setting? Yeah.
- [07:42]
A
Dr. Del Portal, it's really helpful the way that you just broke all of this down. It's fascinating to learn how just that mismatch of patient acuity to facility, how that can cascade into these areas like patient access, the economics and reimbursement piece, and then also patient experience. So, again, appreciate you digging in there and elaborating a bit. And I want to explore the clinical part a little bit more too. You've mentioned some conditions that you've seen patients effectively be treated for in ltch. So are there specific conditions or treatments that you've seen or that you've been most surprised to see ltch handle effectively? And if one comes to mind, could you just share a patient story or anything that you think could help illustrate that?
- [08:29]
B
Sure, yeah. I mean, you look, this, this was an education for me as an emergency physician. I wasn't often seeing the, you know, back end of the transition out of the hospital. And over the past decade or so, I've learned about the capabilities of different facilities. I think sometimes providers and patients tend to lump facilities together that are actually very different. For example, if they think of LTCH as a skilled nursing facility that handles ventilators, when it's really more than that. So I sometimes see physicians wanting to keep patients longer in the hospital for things like a tracheostomy change or a feeding tube placement, or because they're worried that a patient may require blood pressure support or even intensive care. LTCH can do all of those things. So many of those patients can be considered for ltch. And sometimes I have to remind our clinicians of the sort of broad capabilities of an ltch that they can handle. You asked for a patient story. We had one patient who had suffered a really serious aortic dissection, a tearing of his main artery. And he was critically ill and had to have surgery to fix his aorta. And we were able to stabilize him, but he ended up on a ventilator for a prolonged period. And he had a DOP off tube, a special kind of feeding tube that skilled nursing facilities and rehabs just won't touch. And so through our partnership with Kindred ltch, we were able to transfer him there. And he, over the next 28 days, got multidisciplinary support. He weaned off the ventilator to breathe independently. He got his tracheostomy removed. He ultimately transitioned from the feeding tube to a regular diet, he got physical therapy and he was discharged to acute rehab before going home. So there was a lot of hospital days saved for this patient's recovery. And it was transitioning him from the acute care short term acute care hospital to a place really designed to meet his remaining needs in his recovery. And I think, you know, the data I've seen that we share in our partnership shows we're really saving thousands of days in the hospital for patients who meet the criteria for ltch.
- [10:38]
A
Yeah, it's a great example and I really appreciate you sharing that, Dr. Delportal. I know we're talking here about some of the clinical outcomes and especially days saved in the hospital, but I also wanted to give you the chance to, to highlight any other benefits to or changes in hospital operations that you've noticed as a result of getting support from LTCH partnerships.
- [11:00]
B
Yeah, I mean, I think it's really helpful to establish a partnership, you know, that gives us regular reporting of metrics including time from referral to acceptance of a patient, the length of stay of a patient here in the short term acute care hospital and how long they stay at the ltch, and also to track any readmissions. You know, what are the reasons if somebody's not successful at LTCH that, that they need to come back to the short term acute care hospital. That gives us the ability to share outcomes data with our specialty teams that are referring patients and it helps to build confidence in the high level of care that an LTCH can provide. We can identify areas of support that are needed. So, for example, having one of our pulmonologists round at the LTCH at least once a week to check on our patients, support the clinical care there and really link back and give feedback to his colleagues about the patients that they've referred and how they're doing after hospital discharge. I think that's really meaningful for our clinic clinicians. And look, we have a liaison from our LTCH partner that's dedicated to our hospital and we can leverage our electronic medical record and create lists of patients who may meet criteria and have them followed by that clinical liaison who works closely with our case management team. They work with our clinical staff to coordinate some of those aspects of care that I mentioned that are sometimes seen as barriers when really they don't, they don't need to be. They help support the families of patients, they offer tours of their facilities and they answer questions so that it makes the transition from short term to long term acute care hospital less frightening and overall makes the care better coordinated. So, you know, having a robust partnership I think does have a really important impact on hospital operations and clinical quality.
- [12:44]
A
Dr. Del Portal, this has been such an informative conversation. I've learned a lot about the differences between short term care and what's possible in long term acute care. So with all of this in mind, and I know we've covered a lot of ground, I'd love to kind of get your forward looking perspective here. Where is the continuum of care headed and how do you expect that ltch partnerships like the one you've described will evolve as patient needs are growing more complex?
- [13:11]
B
Well, you know, I think if you think about how hospitals and health systems and the challenge before them has evolved over time. Right. You know, hospitals are being charged with doing so much more now than they were decades ago. We have community health workers that are assigned to help patients with the social barriers to health, you know, the transportation, food insecurity, the things that really contribute to making them sick. We've got value based and risk arrangements now that hospitals are more financially at risk for patient outcomes like readmission, complications and frequent acute care utilization. And we've got shrinking margins and a reimbursement structure that isn't really keeping pace with supply and labor costs in health care. So short term hospitals can't do all that alone. Part of my job is looking at where the gaps are in that continuum of care and finding sustainable ways to provide ongoing care outside the short term acute care hospital setting and to smooth the transitions of care. And my experience with ltch is that they can serve as a really helpful role in bridging patients who are too sick from home rehab or skilled nursing, but don't really need all the resources of a short term acute care hospital. By establishing these partnerships, we can really help patients to progress through their recovery at the same time as we can preserve access to that emergency, stabilizing treatment for the communities that we're serving. And if it's put together the right way, I think it's really a win win. So I think the future of where ltch fits in there is potentially an expanded role in, you know, offloading some of the work that acute care hospitals, that short term acute care hospitals are currently doing, because we're being tasked with doing a lot more and expanding our care beyond the walls of the hospital.
- [15:02]
A
It's such an important perspective that you're raising. Dr. Del Portal. I know the capacity crisis in healthcare isn't going anywhere anytime soon. And we know that patient needs seemingly are only growing more complex by the day. So Just kind of hearing your vision for what this would look like in action. You know, these stronger ltch partnerships and how that can offload some burden on other areas of healthcare. It's fascinating to hear about and I just want to thank you again for joining us for the conversation today. Is there anything that we glossed over too quickly or any final thoughts that you wanted to share with our listeners?
- [15:37]
B
I think only that, you know, from the physician perspective, our physicians are so invested in the care and recovery of their patients that they really need to have confidence in those that are going to take care of their patients after discharge from the hospital. So, you know, the importance of partnerships, you know, really strong partnerships is really that, you know, any way we can build bridges beyond our walls that touch and care for our patients, it can be really helpful to find and address any gaps or concerns so our patients can get the care they need and our doctors can get the feedback and follow through to know that someone that they've been so dedicated to caring for is on the right path in their recovery. The best partnerships we have are truly focused on patients needs and they're attentive to those expert physician opinions and those of other caregivers. And so we really appreciate that. I think it's a really important piece of, of this conversation is not just the existence of ltchs, but really how to establish a strong partnership with data sharing back and forth to make sure that we build that confidence and smooth those transitions of care.
- [16:42]
A
Well, it's been great to hear what those partnerships are looking like right now at Temple Dr. Del Portal. So I want to thank you again for, for sharing all of your insights with our listeners and for this great conversation.
- [16:53]
B
Thanks again for having me. Great to join you.
- [16:55]
A
And we'd also like to thank our podcast sponsor for today, Scion Health listeners, be sure to tune into more podcasts from Becker's by visiting our podcast page@beckershospitalreview.com.