History and Common Misconceptions of LTACHs

Ilene Warner-Maron, PHD, RN-BC-CWCN, NHA, assistant professor, Saint Joseph's University, and president, Alden Geriatrics, describes the history and role of long-term acute care hospitals (LTACHs), identifies common misconceptions regarding Medicare reimbursement for LTACH stays, and emphasizes the importance of selecting a nursing home with a consumer mindset.

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 Ilene Warner-Maron, assistant professor at Saint Joseph's University and president of Alden Geriatrics. She describes the history and role of long-term acute care hospitals, identifies common misconceptions regarding Medicare reimbursement for LTACH stays, and emphasizes the importance of selecting a nursing home with a consumer mindset. Dr Warner-Maron?

I'm Ilene Warner-Maron, and I began in long-term care as a teenager in the 1970s. I got my first job as a nursing assistant before we even had certified nursing assistants way back in the '70s and worked as a nursing assistant before going to nursing school from 1978 to 1980 and then becoming a registered nurse. 

After I graduated from nursing school, I worked in a hospital and med surge. I also worked part time as a nursing supervisor, having had absolutely no background, no experience, no nothing, other than having had been in nursing assistant. 

I didn't have a clue as to what I was doing or how to go about doing it, let alone understanding the regulatory framework. I then worked in a hospital for a group of doctors for about 5 years as a case manager before we actually called them case managers. 

I was able to get a sense of what was available in the community for people who were posthospital discharge, how to manage home care, how to get involved with the Area Agencies on Aging for community-based services, what nursing homes were available, and how the system, or the lack thereof a system, actually worked together. 

In the 1990s, I became also licensed as a nursing home administrator. A friend of mine from nursing school had a wound care practice, so I worked for her and became certified in wound care. With that combination of nursing, nursing home administration, and the clinical background in geriatrics and in wound care, that's where I've landed for the last several decades. 

In 1997, the nursing home industry was completely changed because of federal regulations known as OBRA '87. Some people know that as the Nursing Home Reform Act, but it completely changed the way that nursing homes were being regulated. 

A focus on looking at proactivity and care planning, the prevention of wounds, not restraining people, looking at the prevention of infections, and all of those kinds of things. Those regulations were not implemented until around 1990, 1991. We had this huge change in how we did business in long-term care. 

Prior to that, in the early 1980s, regulations changed in terms of hospital billing. Prior to 1984, if you were a patient in a hospital and you stayed days, weeks, months, even a year, the hospital would submit a bill retroactively, and Medicare would pay the hospital for that care.

Beginning in 1984, fully implemented in 1987, was a process known as DRGs, diagnosis-related groups. In DRGs, the hospitals, instead of getting paid at the end of the patient's stay, were paid on a prospective basis. We knew how much that patient was going to be reimbursing that hospital. 

As a consequence, hospitals had to find ways to discharge their patients quicker than ever before, sometimes also sicker than ever before. We saw the growth of the long-term care industry, skilled home health care, and skilled nursing care. We saw growth of those post-acute industries as a consequence of this change in hospital reimbursement. 

What we have now is a system of get people in, stabilize them, fix what you can, and send them home. If they need to come back for second procedure or second diagnosis, we'll do that. 

Then we will have this kind of process where we have the network of hospitals where you have acutely ill people, and then you have the subacute or long-term care industry that's taking care of these people, reimbursed at a much lower level. 

Years ago, when we had people in nursing homes, we had a lot of little old ladies in shawls and rocking chairs. We didn't have a lot of wounds. We didn't have IVs. We didn't do a lot of high-tech interventions. 

In today's long-term care facility, we have all those things. We don't have very many little old ladies in shawls and rocking chairs. Those people are mostly in personal care or assisted living level, but the nursing home has a large proportion of people with complex medical needs who otherwise would have been in that hospital if it wasn't for the DRG issue. 

We've just moved the patient from one place to another. We've changed the reimbursement between the hospital and the nursing home. The reimbursement for that patient is lower, but the needs of that person and the complexity of that person's underlying medical issues is still very prominent and very difficult to manage under some circumstances.

Mostly the LTACHs, what we know as the long-term acute care hospital or post-acute hospital, has the most difficult, most complex residents. 

Those people who are on ventilators, who are difficult to wean, people who have long-term IV antibiotics for osteomyelitis or other kinds of conditions, people who have complex wounds who need serial debridements, people who need blood transfusions very frequently, and also people who have multiorgan failure. 

You'll see people on ventilators and on dialysis who have very, very complex needs. Those people are usually going to be found in those LTACHs, the long-term care hospitals. 

People who have somewhat less complicated medical conditions, who maybe don't need those high-level interventions, or the combination of all those interventions, may be more likely to go to a long-term care facility, a subacute facility rather than an LTACH. 

I think that people really don't understand at all how it fits in the continuum of care. If you look at the continuum of care for older adults, we see that the person who is home, relatively stable, getting care by their PCP, is on the left-hand side of this continuum of care, you may see then the use of home health care from a licensed Medicare home care agency. 

You may see a combination of services provided by the Area Agency on Aging to support the person in the community using Meals on Wheels, assessment, caregivers who come in to provide basic kinds of care. 

Then you have the personal care or assisted living facilities who, unfortunately, some people get confused with the nursing home. Personal care is a level that only provides four basic ADLs, activities of daily living—food, shelter, bathing, those kinds of things. They're not a medical facility. 

If you need a medical facility, then you would go to a skilled nursing facility. Then if you needed even more care, you would go to an LTACH, and then the highest level would be the acute care hospital. Where this LTACH fits into this continuum of care, I think, is the source of confusion.

Now, what you see for a lot of LTACHs in that people will be there for a month, 2 months, 3 months, and then there'll be some pressures to send them to a lower level of care such as a nursing home, but if the person is unable to be weaned from a ventilator, then finding a nursing home bed for somebody who is ventilator-dependent can be more difficult depending on what geographic location that person is residing in. 

There's a major role for people with very complex issues for the LTACH that bridges that person between this subacute facility and the acute care hospital. 

One of the things that is still amazing to me in the year 2021 is that the average consumer has very little understanding about who pays for any kind of long-term care. People really don't understand that Medicare is not a major provider of long-term care, nursing home care. 

In fact, Medicare pays very little for the average nursing home stay. Medicare would reimburse the first 20 days of that admission if and only if that person has been in a hospital for 3-day hospitalization prior to coming to the nursing home. 

The only exception to that is during COVID, you can bypass the hospital and go right to the nursing home if your primary diagnosis is COVID or COVID-related, but otherwise, you'd have to be in the hospital at least for 3 days, go to the skilled nursing facility, and require skilled care. 

What is skilled care? Well, it could be a combination of physical therapy, occupational therapy, speech therapy that will be provided over a period of at least 5 to 6 days a week. It could also be skilled nursing, which is skilled wound care, injections. It could be IV antibiotics. It could be teaching. 

You have to have some kind of skilled need in order to qualify for Medicare to pay for that for that 20 days. While you're in the facility, if you're there for rehab, you have to continue to show slow but steady progress. At the point at which you plateau from that progress, that's the point at which Medicare will no longer pay for your stay. 

Under those circumstances, people hear that Medicare will pay for up to 100 days of their nursing home stay when in reality, that's not how much time people are going to have. They're going to have 100% at 20 days. They'll have a copay from day 21 to day 100, but they're likely to not even get a full 100 days of that Medicare benefit based upon with their progress is or their lack of progress.

After that 100th day or at the time that Medicare no longer is paying for your care because you're no longer deemed skilled, then that person has to either pay out of pocket or begin a Medicaid process where they're applying for the Medicaid to pay for their long-term care. 

That often requires the property that they have to be sold or assigned to the state. It does require that the person spend down to the point where they're Medicaid-eligible financially. There a lot of moving parts involved with applying for Medicaid and making sure that that person is financially as well as medically requiring this kind of care in a long-term care facility.

I would really try to encourage people to go the consumer route. We know that there is really a lack of consumerism in long-term care. People still tell me that they picked a particular nursing home because it was near their office or near their home. That's how you buy a piece of real estate, but that's not how you select a long-term care facility for a loved one. 

There's a lack of understanding generally about what's available, what kind of services, what's the difference between assisted living and nursing home, and people really don't even understand that concept of the LTACH. 

I think talking to consumers about what kinds of services, what are the range of services that an LTACH can offer, would be really helpful in improving the understanding of consumers, not necessarily the people who have somebody right now who they're thinking of placing but thinking about what's available in your community in the event that you or your family member may need such a placement.

Finding ways to think about our future is something that we don't want to think about. I know that there are people who've already planned their funerals, who've already decided what psalms will be sung, and what parts of the Bible will be read during their funeral, what they want to wear.

We really need to think about what happens or what could happen between that time, between the time that we are independent and the time when we're no longer living, and to think about what's available in our community. What kind of range of services might we need? What do we want to do now about going out, looking at that, assessing where we want to go, understanding what kinds of limitations are available? 

What range of services are available in various facilities so we'll be a better consumer, so we won't be taken advantage of, so we'll be able to financially, morally, ethically, medically, and nursing-wise understand what's available to us so that we can be good consumers of long-term care.

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