Postacute care, rehabilitation, and long-term care systems

Introduction

The physician assistant (PA) profession is rooted in primary care; however, increasing numbers of PAs are choosing specialty areas. According to the 2018 American Academy of Physician Assistants’ salary report, 34% of PAs reported practicing in a hospital setting, whereas 56% remained in an outpatient setting (family and general medicine, internal medicine, pediatrics, and other specialty clinics or facilities). Although most medical care continues to be delivered in traditional settings, such as outpatient offices, ambulatory care centers, and acute care hospitals, there is a growing trend for care to take place in the patient’s home or in an initial posthospitalization setting. This trend is fueled by the aging “baby boomer” population, the need to decrease costs, and the personal desire of individuals to stay in their own homes. That home may be an individual domicile, congregate housing, assisted living facility (ALF), skilled nursing facility (SNF), nursing home facility (NHF), long-term acute care facility (LTAC), or hospice. Because of the rapid increase in demand for such services and ongoing changes in legislature, the need for PAs in nontraditional medical care settings is growing.

The goal of this chapter is to provide an overview of care delivery in a variety of settings and to help readers gain an understanding of patient options and the principles of the transition of care between facilities. Figure 46.1 , provided by The Hospitalist, gives an overview of the various facilities discussed in this chapter, and Table 46.1 provides an in-depth summary of these sites of care.

The “silvering” of the U.S. population is a well-established trend largely because of the aging of the “baby boomer” population. In the decade from 2020 to 2030, the population aged 65 and over is projected to increase by 18 million (from 56 million to 74 million). There is no doubt that this demographic shift will result in an aging “tsunami” of need for all kinds of care: medical, psychological, social, and rehabilitative. These needs will become an impetus for change in the U.S. health care system. Many patients will require postacute care (PAC) for ongoing medical needs, rehabilitation, and palliative care. Of the nearly 8 million people hospitalized in 2013, 22.3% were discharged to postacute settings. The transitioning of care to the appropriate setting for every patient is instrumental in maximizing the patient’s medical and functional recovery, regardless of age.

The PA training model emphasizes collaborative care and generalist training and thus equips PAs to readily take care of this fragile patient population. PAs play a pivotal provider role in all aspects of patient care, including management of active medical conditions, careful consideration of patient goals, functional implications of various medical conditions, communication with families and support staff, advocacy for patients, and facilitation of the transition of care in both inpatient and outpatient settings. Therefore it is essential to understand all components of the home health and postacute care medical systems in addition to the complex health care payer system. Most of the health care of older adults and disabled younger individuals is financed by Medicare, administered by the Centers for Medicare & Medicaid Services (CMS). Further information on reimbursement is provided in each section.

Home care