Differentiating Between Long-Term Care Facilities and LTACHs

Richard Stefanacci, DO, MGH, MBA, AGSF, CMD, senior physician, Trinity Health PACE, compares long-term acute care hospitals (LTACHs) with other long-term care facilities and offers insight on how LTACHs might ensure they receive the appropriate patient populations by specializing in a particular area of care and educating referral networks.

Read the full transcript:

Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more. 

Today, we are joined by Dr Richard Stefanacci, senior physician at Trinity Health PACE. He compares long-term acute care hospitals with other long-term care facilities and offers insight on how LTACHs might ensure they receive the appropriate patient populations by specializing in a particular area of care and educating referral networks. Dr Stefanacci?

My name is Dr Richard Stefanacci. I'm a practicing internist/geriatrician, practicing in the Philadelphia area. I also had the opportunity to spend a year at CMS as a health policy scholar and teach at Thomas Jefferson in the College of Population Health. In addition to that, my family owns and operates three long-term care facilities.

Can you talk a little bit about the difference between long-term post-acute care facilities and hospitals? 

Sure. It's commonly referred to as LTACH, long-term acute care hospitals, and people just say LTACH for short. 

It's important to know that hospitals operate under what's called a DRG or diagnostic-related groups, so they get a lump sum for a specific illness that the patient's in for. Hospitals are very much driven towards getting patients out as soon as possible, as well as patients, as you can imagine.

LTACHs, on the other hand, are paid more on a daily rate. There's not that pressure to get people out quickly. It's really more towards focusing on what's best for the patient. The difference is, primarily, that the acute care hospital takes care of the acute issue. 

When somebody is going through—you want to think about it as—maintenance type therapy, not as acute therapy, it would move to an LTACH for things like continuing to be weaned off a ventilator, or long-term IV antibiotic therapy, or long-term wound care therapy. Those are some of the big three that are typically taken care of in an LTACH.

What helps determine if a patient should go to a long-term care facility or an LTACH?

I think of it as four places to go after leaving the hospital. For the most acute patients and ones needing the most or the highest level of care, it's LTACH. The step below that is typically IRF or inpatient rehab facility, and then underneath that is subacute, typically in a skilled nursing facility, and then home care. 

Those patients needing that higher level of care in an LTACH typically have had a fairly intense—and I mean that in a few senses of the word intense—hospitalization. They've been in the ICU. It's been a long course. They've had some complications. 

Those are the patients most appropriate for an LTACH, where they're going to be somewhere for a longer period of time. They need daily physician visits from a physician such as myself, and they're actively working on some type of treatment, either IV therapy, wound care, or ventilator respiratory support that they’re trying to get them off of.

What are some of the common misconceptions of an LTACH?

I think the biggest misconception is that you need to be hospital-level care. That's clearly not the point. Hospitals are for hospitals, again, for the acute care issue. LTACHs, again, are for long stay, active treatment. 

There are patients that wind up in alternative care settings, whether that's an IRF, or subacute, or even worse than that at home, that would be appropriate for an LTACH. 

I think the biggest misconception is the level of severity that a patient needs to be to get to an LTACH. I think that clinicians, both in the community and the hospital, need to think LTACH more readily so those patients that are appropriate for LTACHs are being referred there.

Along with these misconceptions, we also have a little bit of limited information surrounding the costs associated with post-acute care. What can you tell us about the costs linked with these programs?

Just as I mentioned those four levels of care—LTACH, IRF, subacute, home—the costs follow that because, again, the intensity of services are more significant at the LTACH level as opposed to home. The costs are corresponding. You get what you pay for. 

Again, LTACHs tend to be the most expensive of those four. Home care tend to be the least. LTACHs, on average, are around the cost of the daily rate in the hospital. Again, because it's an intensive service, a lot of LTACHs pressingly physically attached to hospitals. 

IRFs or inpatient rehab facilities are around $1,000 a day. The average length of stay there's about 13 days. SNFs, subacute units, are around $550, average length of stay between 14 and 20 days. Again, home care being the least expensive of the four.

What advice can you offer to LTACHs who are looking to differentiate themselves from a long-term care facility?

It's not just differentiating. The real question is, how can LTACHs get the appropriate patients and be an important part of the continuum of care? It's really two buckets. 

One is to specialize in a particular area that they can really have significant expertise, whether that'd be wound care, ventilator support. Those are two big ones. The other part is to go out there and educate that referral network so that they are appropriately referring patients to you. That's, a lot of times, from the hospital side. 

Then even more than educate, I think it's critical that the LTACH be part of that continuum team that they could help right from a patient that's critical getting admitted so that it can be on the radar that people are thinking after the patient's done with the acute stay, the next stay for them is an LTACH. 

I think differentiating themselves by specializing in a particular area, educating the hospitalists, being part of that team, and making sure patients get there appropriately.

Just overall, is there anything else you'd like to add to this conversation today?

The big thing to add is just to summarize that, is really when you think about post-acute care, four big buckets—LTACH, IRF, subacute, home—the key is keep all those top of mind to make sure that patients are appropriately discharged or transitioned, rather, at the appropriate time and to the appropriate care setting. 

LTACH is something that people should consider when they're looking at post-acute transitions from the hospital.

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