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What is the Right Level of Care?

September 25, 2017
Healthcare Consulting By Cathy Benfer

Every day there seems to be yet another alternative to level of care for people seeking assistance with healthcare and other essential living needs. While it may be confusing, the wide berth of available services is necessary for people to receive the most appropriate level of care. Let’s look at the services most widely used in healthcare today.

 

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Hospitals

Of course this level is self-explanatory. If a patient has an acute (having severe symptoms and short course) illness, accident, injury or significant change in a long-term health issue, they would be seen in a traditional hospital setting. Dependent upon the specific illness, or need, a hospital stay can be as short as 24 hours or longer. Staff the patient might meet in a hospital setting could be emergency room staff nurses and physicians. If a hospital admission occurs, a patient may also interact with a hospitalist (a physician employed by the hospital who oversees the care during the hospital stay), possibly the patient’s own primary care physician if he/she has admitting privileges at the hospital, a physician assistant, nurses or other medical specialists within the hospital. These stays are typically covered by insurance. Sometimes a viable alternative may be an urgent care center if the condition is not critical. Often hospitals have urgent care centers that are stand-alone locations, but they may be connected to the hospital if a patient has a critical need or condition.

According to the Centers for Disease Control there are over 130 million emergency room visits in the U.S. every year. Of those ER visits, approximately 9% result in admissions.

Long Term Acute Care Hospitals

As identified by the American Hospital Association, Long-Term Care Hospitals (LTCHs) furnish extended medical and rehabilitative care to individuals with clinically complex problems, such as multiple acute or chronic conditions that need hospital-level care for relatively extended periods. To qualify as an LTCH for Medicare payment, a facility must meet Medicare's conditions of participation for acute care hospitals and have an average inpatient length of stay greater than 25 days. In 2015, Medicare spent $5.3 billion on care provided in LTCHs nationwide. About 116,000 beneficiaries had roughly 131,000 LTCH stays. This setting provides a hospital environment for people who may have significant illnesses related to cardiac, respiratory, neurological or infectious disease issues.  Patient’s might interact with staff such as: physicians, (including physician assistants and specialists), nurses and physical, occupational, speech or respiratory therapists. These stays typically require approval through a case manager at the insurance company prior to admission. Most often a patient would be admitted here after a stay in a traditional hospital however still requiring significant hospital services. These locations could be stand alone or within an existing hospital.

Rehabilitation Hospitals

These settings provide intense physical, occupational and/or speech therapy; which is designed to return an individual to their level of functioning prior to the current, significant illness or injury. The patient is required to participate in at least 3 hours of therapy per day at this level of care and often receives therapy multiple times during the day. Staff interaction would include: nurses, nursing assistants, physical, occupational, speech therapy as well as a case manager and social worker. Additionally, a physician will visit periodically throughout the stay. Typically, insurance will cover up to a pre-approved number of days provided the patient continues to progress in achieving the goals set by the therapist.

Skilled Nursing Facilities

If a patient cannot withstand the intensity of 3 hours of therapy per day due to debilitation or diagnosis, skilled nursing is a viable alternative. Patients will still receive therapy, but at a less intense level than at a rehabilitation hospital. Contingent on insurance, a stay at a Skilled Nursing Facility can range between 1–60 days. According to Medicare, the following is a breakdown regarding skilled nursing coverage.

  • Days 1–20: $0 for each benefit period. (Benefit period begins the day you are admitted to a hospital or skilled nursing facility and ends when you have not received services for 60 consecutive days.)
  • Days 21–100: $164.50 coinsurance per day of each benefit period. (The amount you or your additional insurance would pay as the cost of services after you pay any deductibles. This cost is usually a percentage, for example 20%)
  • Days 101 and beyond: all costs.

Often, traditional insurance coverage is determined through a pre-authorization with the insurance company. Interaction with staff would include: nurses; nursing assistants; physical, occupational, speech therapy; a social worker or case manager; a physician (usually employed by the facility); and the administrative staff of the facility, including but not limited to the Nursing Home Administrator, Director of Nursing and the Registered Nurse Assessment Coordinator.

Assisted Living and Personal Care

These levels of care are “residential” in nature and assist residents to accomplish activities of daily living such as bathing, dressing, hygiene, laundry, meals, and if needed, therapy on an outpatient basis. Each resident may have their own apartment or may share living space with another individual, contingent on pricing and their ability to pay. Typically, unless an individual has long term care insurance, this level of care is paid for on a private pay basis. The average cost of Assisted Living is between $60–$80 per day ($1,800–$2,400 per month for basic care).

Home Health

This setting takes place in the patient’s own home and a physician’s order is required. One of the main criteria for insurance coverage for this level of care is the status of “home bound.” This means that the patient is not able to freely leave their home unless they are going to a physician or other medical appointment. These services include physical, occupational, speech therapy and possibly nursing visits. The Home Health staff member would visit the patient 2–3 time per week for approximately 1 hour each time. Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance) covers eligible home health services like these:

  • Intermittent skilled nursing care
  • Physical therapy
  • Speech-language pathology services
  • Continued occupational services and more

Usually, a home health care agency coordinates the services your doctor orders.

These services are designed to be short term and intermittent in nature and not meant to last for more than a few weeks. Services under Home Health Care are typically covered by insurance after an authorization is obtained. Staff you may interact with would be therapists, nurses, and nursing assistants.

Home Care

This level of care is typically not covered by insurance unless the person has long-term care insurance or is eligible for a state Medicaid program.

 Medicare does not pay for:

These services would include private duty care to assist with things such as bathing, dressing, hygiene, light housekeeping, meal preparation and sometimes transportation to appointments. Care is provided to the client in their own home. Staff you may interact with at this level of care would be nurses and nursing assistants.

While navigating these levels of care will be undoubtedly confusing, ask your health care provider for clarification. Have someone you trust with you when you are making decisions about the most appropriate level of care for your needs, and talk with them about what your healthcare provider has told you. Keep in mind that you do have choices when it comes to your care. Ask your health care provider to furnish a list of the providers at the recommended level(s) so that you can make an informed decision.