hsc 6636: acute care 1 dr. lawrence west, health management and informatics department, university...

HSC 6636: Acute Care

1Dr. Lawrence West, Health Management and Informatics Department, University of Central Floridahttp://systems.cohpa.ucf.edu/lwest

Topics

• History• Categories of Acute Care• Acute Care in Hospitals• Hospital Organization• Issues and Trends

“Over several decades, an increasing proportion of acute care has moved to outpatient settings driven by financial incentives, advances in medical technology, and physician and patient preferences.”

Text (p. 192)



History

• The history of acute care includes themes we have seen before

• 1800s and before saw acute care primarily home-centered– Family care ‒ Non physician practitioners– Physicians ‒ Little role for hospitals



History (cont.)

• Early 1900s saw increased roles for hospitals– Improved hygiene, asepsis, and anesthesia and

improving equipment • Improved hospital outcomes• Shifted demand for hospital services

(displacing some home care)• Displaced long term care provided in hospitals

– Solo practitioner physician—hospital relationship takes shape



History

• WW II Era and Beyond– Increased effectiveness, availability, and demand

for acute care services, including hospitalization• Antibiotics • Health insurance• Hospital subsidies • Medicare/Medicaid

• Modern Era– Increased reliance on NP and PA– Wide range of settings for care



Categories of Acute Care

• Ambulatory – Outpatient basis w/ no overnight hospital stay– Many settings– Less of a longitudinal relationship between patient

and provider



Categories of Acute Care (cont.)

• Ambulatory Care (cont.)– Conditions for which ambulatory care has

traditionally been provided– Shifting new conditions to ambulatory status

• New technologies reduce hospitalization• Cost containment pushes “elective”

hospitalization into ambulatory arena• Reducing hospital stays pushes more follow-up

care to ambulatory setting• Managing chronic conditions reduces demands

for hospitalization for acute episodes




• Ambulatory Care Statistics– 82% of ambulatory visits to physician offices– 8% hospital outpatient departments– 10% to hospital emergency departments– 3.8 visits per person per year– Highest usage from more affluent, white, women

• Also higher usage of physician offices• Less affluent rely on emergency departments




• Ambulatory Care Organization– Physician offices account for majority of visits– New delivery methods often hospital sponsored to

reduce demands on hospital facilities• Walk-in clinics• Outpatient clinics• Stand-alone surgery centers




• Primary Care– Expectation of longer term relationship between

provider and patient– “A person seeking medical care directly from

various subspecialists as the need may arise, but who has no principal ongoing relationship with any of them, would be using ambulatory care but not primary care.” (p. 197)




• Primary Care (cont.)– Taking on increased prominence with rise of MCO– Providers include

• Physicians • Nurse Practitioners *• PAs * • Nurse-midwives

– * Can perform 75-90% of services a physician usually provides

– Some specialists may become PCP for appropriate patients




• Emergency Care– Multiple roles

• True emergencies– Recognized medical specialty– Specific equipment and procedures

• Walk-in for less ill– Uninsured– Uncertain

• Resource rich primary care environment to assess patients with serious problems




• Specialty Care– Care by specialists for acute conditions– Surgical ambulatory care for less debilitating

procedures• 16.4% of surgery outpatient in 1980• 63% outpatient by 2005

– Imaging services provided through• Specialty imaging practices• Physician offices



Acute Care in Hospitals



Acute Care in Hospitals (cont.)

• Behind the Numbers– Increasing population

• Admissions per person holding steady– Aging population– Crowding– Demand for outpatient services




• Teaching Hospitals– Part of an academic medical school and/or;– Offer residency programs– May have medical school faculty on staff– Disproportionate share of uncompensated care

delivery– Mixed benefits to patients

• Much care delivered by trainees• Access to highly qualified faculty




• Public Hospitals– Supported by government funds (in addition to

fees)• Direct operation by government• Operation by a separate government

supervised agency• Operated by a not for profit company under

contract with a government– Often serve underserved areas




• Public Hospitals (cont.)– Typically larger when in urban areas– “Safety Net” providers– Only 2% of nation’s hospitals but provide 25% of

uncompensated care– Other community roles

• Public health• Outreach and education• Disaster planning




• Rural Hospitals– About 2/5 of hospitals classified as ‘rural’– Much smaller than urban hospitals– Facing shifting demographics

• Older and poorer– Difficulty providing expensive technologies

• Difficulty attracting physicians– Disproportionately hit by Medicare reductions but

with some offsets




• Multihospital/Integrated Healthcare Systems– Half of hospitals part of larger entities

• Chains or networks• Holding companies• HMO

– Network: Group of providers working together– Multihospital System: Members under the same

management umbrella• Often an ownership relationship

– Alliance: A formal organization to integrate operations of members



Hospital Organization

• Hospitals which of a wide range of services to provide– Driven by available practitioners– Needed investment– Demand & competition

• Physicians control admissions• Hospitals provide support services

– Labs ‒ Imaging– Pharmacies ‒ Facilities– Nursing ‒ etc.



Hospital Organization (cont.)

• Physician Relationships– Previous coverage– Note that physician orders for hospital services are

not paid by the physicians• Governance structures

– Traditional/departmental—dual authority structure– Divisional—more integrated support services– Independent-corporate—Medical stall a separate

legal entity– Parallel—Professionals time-share their efforts



Hospital Organization (cont.)

• Governance models can vary– Often committees with varying authority– Management staff– Executive committee– Board of directors



Issues and Trends

• Team Based Care– Construct a team focused on the patient’s needs– Leverages each member’s expertise– Minimizes distractions away from primary strength– Minimizes on-site time for office-based members

• Patient-Centered Care– Recognizes need for patient engagement– Incorporate patient preferences– Has lead to reduced aggressive treatments



Issues and Trends (cont.)

• Physician Training– New trends recognize pros and cons of managed

care trends– Emphasize continuity of care including outside of

hospital setting– Reducing residency work requirements

• Increases demands for physician extenders




• Access to Care– Acute care providers must deal with number of

uninsured/underinsured patients– $40.7 billion cost for uncompensated care in 2004– Increasing complexity of conditions as patients

defer care




• Costs of Care– Cost containment strategies addressing

• Reimbursement mechanisms• Changes to practice including managed care• More aggressive resource management

– Shifting more care to ambulatory environment– Addressing administrative complexities– Increasing use of information technologies

hsc 6636: acute care 1 dr. lawrence west, health management and informatics department, university...

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