Subacute Care: The Road Ahead

Author Affiliations:

Dr. Buxbaum is Clinical Associate Professor of Medicine, Harvard Medical School, Boston, MA.
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Introduction

A previous article defined subacute care and described its brief history and present status in the spectrum of inpatient care.¹ Since subacute care is undergoing constant expansion and evolution, it seems appropriate to look at the near- and long-term possibilities for progress. This article aims to lay out a number of areas for expansion in the near future. Not many of these have actually been realized, some have not even been considered or discussed, and there is considerable uncertainty about how and under what auspices these enhancements would or could be financed. However, uncertainty is no argument against planning for allocation of resources. Further, if debate is absent, decisions about subacute care will be left to agencies and individuals with no history of involvement in the field. Thus, we are at a time when experts—gerontologists, geriatricians, health policy experts, academicians—and those with experience in subacute care should meet, discuss, and plan the future of the field. In the previous article, the rationale for subacute care’s creation and status was cited: the well-recognized growth of the elderly population, the role of short lengths of stay in hospitals, and the cost advantage that subacute care offers in contrast to typical hospital bed-day charges. Mention was made of the possibility that subacute care could offer more than simply rehabilitation services. A different kind of casemix reimbursement formula, taking into account both the needs of patients and the skills offered by enhanced subacute services, would justify a rethinking of what subacute care is and could become.

This article will examine some potential avenues for development consistent with the nature of subacute care. Clearly, these are just a beginning, and readers are encouraged to offer their own views and critiques. The topics discussed here are: Geriatric Assessment, Rational Pharmacology, and Palliative Care. A fourth topic, Teaching Opportunities in Subacute Care, will be addressed in a forthcoming article. Think of subacute care as a passageway through which increasing numbers of patients travel. What happens during that experience can range from a set of basic rehabilitation services to a much richer array of therapy, teaching, and medical progress. While the majority of those referred to subacute care consists of older patients with multiple comorbidities, a sizeable minority is younger, also seriously impaired, and sometimes terminally ill. Medical, and often psychosocial, complexity characterizes subacute care. Most individuals come on referral from a neighboring hospital, often with little more than the notion that “rehabilitation” (whatever that means) is the next step. And to be perfectly honest about this, many rehabilitation/subacute centers are oriented only around that one goal. Opportunities abound, but are insufficiently seized. So what is possible, and what might be the future of subacute care?

Geriatric Assessment

Given the demographic characteristics of American families, along with the growth of the elderly population, one fact is that increasing numbers of middle-aged people have significant concerns and responsibilities for their elderly family members’ health and well-being. This often comes at a time when members of the “Sandwich Generation” are trying to raise their children, pay for college educations for their kids, or deal with their own unique needs. Most often, care for their parents suddenly looms as a crisis, totally unexpected and unplanned. This, for many families, is like an earthquake. Geographic separation adds to the distress. Lack of prior preparation (some would say denial) characterizes this process. Great skill is needed to manage these events, and for healthcare professionals to restrict interventions to medical management alone is to disregard and delimit the overall needs of the patient and family.²

Many admissions to subacute facilities are crisis-driven. If families were not already thinking about the future health of their loved ones, the experience of hospitalization and subsequent stays in subacute care tends to focus the mind. In subacute care, skills and personnel needed for geriatric assessment are already a part of the daily fabric of the best facilities. Further, the family meeting, already a major component of the subacute modus operandi, offers an opening, a forum, in which to introduce difficult topics and to search for a care plan. Mediating family disputes, managing anger and disappointment, and developing a rational care plan are what subacute units can do better than most other venues, given the teamwork that already exists there, along with bonding with patients and their loved ones. In other words, a form of geriatric assessment (whether one calls it that or not) is already present. It is the view of this article that any debate about what Comprehensive Geriatric Assessment (CGA) is or is not should hold little interest for the subacute care sector; what should attract our interest is:

• How to develop our unique version of CGA
• How to define the field as it relates to our clients: patients, their families, and their primary medical teams
• How to market the process
• How to evaluate the results

Geriatric assessment entered our vocabulary in the mid-20th century, when Dr. Marjory Warren in the United Kingdom systematically evaluated bedridden patients in a workhouse newly assigned to the chronic disease hospital where she worked.³ There she provided some clients with rehabilitation and succeeded in many cases to maximize their function enough to return home. This effort, begun in 1935, became the genesis of present-day geriatrics; geriatric assessment, the technique that she single-handedly invented, is a part of her legacy.⁴ Characteristically, the field of CGA has developed and then retreated, and exists presently in a few institutions, not altogether a part of the mainstream medical care system. The most robust expression of the field is perhaps in Great Britain.⁵ In the United States, the most developed sector has been in the U.S. Department of Veterans Affairs hospitals and clinics.

The elements typically contained within such an evaluation program consist of medical assessment, functional measurement, psychological evaluation, social appraisal, and environmental review. A comprehensive review of the field by Wieland and Hirth⁶ speaks to the generally positive and reproducible, if not dramatic, results gained from such interventions, but it speaks also to the variability in outcome depending upon the setting in which the program is located and its clientele. Studies are therefore not capable of giving total reassurance that CGA is a tool that embodies great power. But are there other uses for CGA, for instance, in the subacute setting, that could be equally important to patients and caregivers?

If CGA looks at functional capacity, instrumental activities of daily living, falls prevention, psychological or social issues, as well as the social, housing, financial, and legal dimensions of the patient’s world, the question remains: Is there a role for such activities within subacute care? The answer, it seems fair to say, is yes, especially if the subacute sector is willing to innovate and experiment with family-friendly versions of this technique. Although sometimes crisis-driven, geriatric assessment programs could also serve as a model for elective consultative services on request by families. An important article published in the mid-1990’s concluded that inpatient-based geriatric consultative services significantly affected neither mortality reduction nor functional well-being.⁷ However, there is a sense that a need exists. If the consultative initiative defines its clients and makes no assertions about prolonging life or even maximizing function, the predictive knowledge itself can have meaning for those who bear responsibility for their aged parents.

Knowing what may lie ahead and assisting in planning around those dimensions have their own value. Again, the locus could be a subacute facility with such skills, perhaps combined with an affiliated geriatrics medical service. Such innovative consultative programs would help to educate a new clientele in the need for planning. As the Baby Boomer generation approaches old age, the need for such expertise will undoubtedly grow. Many readers of this journal will have had experiences related to at least some of these areas of concern in their own families or circle of friends, as well as in the families of patients under their care. As a new initiative, this approach would need to have a solid business plan as well as market testing; but the signs now all point to a large reservoir of need, with few programs addressing the potential demand. Again, subacute care programs could become the springboard for such forward-looking initiatives.

Rational Pharmacology

An essential source of useful information for those healthcare providers who practice geriatrics is the Updated Beers Criteria,⁸ a system of classification by individual drugs, classes of drugs, and diseases in which certain drugs should be avoided. This scheme should be the standard of practice for all facilities and healthcare professionals who care for elderly patients. Concerns about drug use involve a number of areas:

• Drug interactions
• Drug toxicity
• Drug allergies
• Costs
• Routes and times of administration
• Monitoring

Patients who come to subacute care facilities are mainly recent transfers from tertiary hospitals. In the hospital setting, most house officers, and probably few attending physicians as well, express much concern about drug costs; this tends to be relatively intransparent to those providers.⁹ There is an increasing tendency to use new and more powerful drugs, particularly in the care of infectious and cardiac diseases. Interventions to try to change hospital-based physicians’ understanding of this have led to modest success, but there are few interventions aimed at this goal, and no long-term follow-up studies.¹⁰ Thus, as the geriatric patient traverses the subacute “funnel,” efforts to rationalize, explain the use of, teach about, and make economic sense of, each person’s drug list become increasingly urgent.

Collaboration with pharmacists and other consultants in this work could yield immense benefits in terms of patient safety, costs to the system, and patient well-being. The time spent in educating patients and families using a variety of techniques (video, printed materials, individual counseling, and computer-based programs) would be well worth the small investment in supports. A patient who enters with an unmanageable, costly drug list and is discharged with something less cumbersome, safer, and less costly is a more satisfied client. Simultaneously justifying the approach and soliciting the support of the patient’s medical team is a valid consultative function.

Palliative Care

Hand in hand with geriatric-oriented subacute care is the practice of palliative medicine. What palliative care is, on the other hand, is a little hard to pin down. An excerpt of one definition of palliative care follows (see website for entire quote): Palliative care (from Latin palliare, to cloak) is any form of medical care or treatment that concentrates on reducing the severity of disease symptoms, rather than providing a cure. The goal is to prevent and relieve suffering and to improve quality of life for people facing serious, complex illness.¹¹ Here is part of another definition of palliative care from the American Academy of Hospice and Palliative Medicine (AAHPM): The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies. Palliative care is both a philosophy of care and an organized, highly structured system for delivering care.¹²

The problem for both palliative care professionals and those looking in from the outside is that there really is no good definition of this still-emerging field. The definitions are prolix and not likely to be well understood by most reading them, even if they were willing to devote the time and energy needed to do so. Those given above are only two current definitions; there are others. All strive to make sense of what palliative care actually is. For now, it is probably accurate to say that we know palliative care when we see it; it just can’t be described well in words. (The problem isn’t limited to palliative care; internal medicine is in a similar identity crisis.) Distinguishing between what professionals in so-called “palliative care practices” do contrasted with their colleagues in hospices is not always easy. Palliative Medicine as a recognized specialty is now sanctioned by the American Board of Medical Specialties (ABMS); the first fully-recognized board exam took place in October 2008. Prior to this, the board certification process, while rigorous, was sponsored and recognized only by the AAHPM. More focused, however, is this characterization of the palliative medical specialist from AAHPM.

Specialty-Level Palliative Care

Palliative care is both a general approach to patient care that should be routinely integrated with disease-modifying therapies and a growing practice specialty for appropriately trained physicians, nurses, social workers, chaplains and others whose expertise is required to optimize quality of life for those with life-threatening or debilitating chronic illness. Primary practitioners, in the routine course of providing health care, are expected to provide basic elements of palliative care (eg, pain and symptom assessment and management, advance care planning). In other cases, complexity may determine that the patient or their family requires the services of palliative care specialists. Specialist palliative care providers are professionals whose work is largely or entirely involved with palliative care and who have received appropriate training and credentialing in the field.¹³

While this definition does not really tell us much about the working milieu or guidelines of practice for physicians, nurses, and others who wish to provide care for patients with complex needs, it at least provides a fairly accurate description of what a person who calls himself or herself a palliative care specialist is. What and where he or she does this is another matter. Certainly, programs in hospitals exist, with many brought into being by the Center to Advance Palliative Care (CAPC).¹⁴ While defining palliative care and who does it may not be easy, there is a certain utility in thinking about the locus of such care. The following might serve as one example for the integration of palliative care into the world of practice:

Palliative care could flourish as a major enhancement within subacute care. In other words, integrating palliative concepts and certified medical personnel, advanced care practitioners, and nursing specialists into the working environment of subacute care offers an expanded approach to patient needs, as well as a rich set of tools for professionals who care for such patients:

pain and symptom control, complex decision-making, grounding in bioethics, integration with hospice care, teamwork, skill in meeting family needs, and bereavement support, among others. This, in fact, is the model of this author’s work milieu:

Of the four physicians who practice on the subacute/extended care facility team (in a large, urban multispecialty group practice), three are certified palliative care specialists, all are internal medicine-certified, one has in addition a geriatrics certification, and one is a Fellow of the AAHPM, a recognition of advanced status.

Two of the seven nurse practitioners in the group have also achieved their palliative care certification, and others are working toward such. Most patients entering subacute units come with multiple comorbidities and complex needs. Death is frequently a part of the equation, often unacknowledged. Healthcare professionals are often as likely to deny the possibility of death as family members.¹⁵ Thus, while the team may begin by concentrating on rehabilitation and restoration of health, everyone must be aware that success may be elusive, and must therefore prepare for the kind of care that will enhance the quality of remaining life.

When rehabilitation efforts do not provide the hoped-for improvement in function, and when excellent medical care fails to provide benefit, bringing palliative medical initiatives to the bedside can transform a bad medical outcome into a good end-of-life experience. Not that one can mitigate the sadness and sense of loss that accompanies decline and death, but at least the team, family, and patient can be given all of the benefits that are available to the dying person: pain relief, symptom relief, concern alleviation, pastoral care, social service support, hospice care (in collaboration in the facility or on referral to home or residential hospice), and access to resources that make a difference. This is the time to “de-medicalize” the illness and to turn toward taking care of the whole person; caring for the patient to the end, given the right resources and support, is a duty as well as a privilege.¹⁶

Using the subacute practice as a locus for palliative care initiatives, these same specialists can also provide consulting services for affiliated hospitals. In our experience, this is valuable not only for patients and their families in those settings, but also for attending physicians, house officers, and medical students. In the world of hospital medicine, provision of palliative consultative services can bring considerable benefit to the patient in pain or with intractable symptoms, family meetings at the hospital can add value, and in all settings—hospital, subacute units, long-term care, and in the home—bioethical issues remain preeminent.

Finally, a brief case:

Mrs. L is a 90-year-old woman with metastatic bladder cancer. At home, she has had anorexia and has lost 23 pounds in the past 2 months. She has an ileal pouch and complains of lower abdominal pain. She is seen in the hospital on consultation by a palliative care specialist who was called by the medical attending physician, who states: “We aren’t doing anything for her; there’s no surgical or medical fix for her problem, and we haven’t done a good job of controlling her pain. The patient wants to die; she doesn’t want to eat. But her family is insisting that we do something for her to make her gain weight.” Her albumin level is 1.8 g/dL, hematocrit 27%, white blood cell count 8000/mm3, electrolytes show a picture of dehydration; creatinine is 3.2 mg/dL, BUN is 86 mg/dL. She is taking oxycodone as needed for pain. She is cachectic, drowsy but arousable, and points to her lower abdomen when asked about pain.

The major finding is a relative absence of bowel sounds. The consultant recommends a bowel regime (first checking for impaction), finding that none is on the orders. She recommends switching from as-needed oxycodone to hydromorphone 1 mg/mL oral solution, 0.5 mg every 6 hours as needed for pain, withholding for drowsiness or reduced respirations. The consultant arranges to come back the next day to meet with the patient and family. In the family meeting, the consultant listens to each member’s concerns. Regarding the pain, she explains that the most likely source of distress was constipation. In fact, now that Mrs. L has had a bowel movement, she is more comfortable, although it’s difficult to tell whether that made all the difference or if the new opioid has improved the situation.

The patient is not excessively drowsy. The consultant explains that the patient is probably too cachectic to benefit from transdermal fentanyl, and switching to methadone (both drugs are not renally excreted) is not practical at this late stage. Oxycodone and morphine are contraindicated in renal insufficiency; hydromorphone may be used with caution and appropriate monitoring. The hydromorphone, in fact, is needed rarely. The consultant responds to the family’s concern about Mrs. L “starving to death.” She explains that not eating is a choice that many dying patients make, and most are not distressed by not eating. Mrs. L affirms this as the family meets at her bedside. The consultant explains that feeding tubes and other artificial means of providing nutrition have almost no role in the care of the dying person. She gives them material to read published by a local hospice on this subject and agrees to be available to discuss the issue further when and if they wish to do so.

The patient agrees to a Do-Not-Resuscitate/Do-Not-Intubate order and identifies a daughter as her healthcare proxy. The consultant suggests brief placement in a subacute unit, where palliative specialists are available along with rehabilitation personnel. Further hospitalization is not needed. The patient and family agree, and she is discharged to the facility a day later. In the facility, she is evaluated by the therapy staff, attending physician and nurse practitioner, nutritionist, and social worker. As expected, she cannot perform at a level that would allow physical or occupational therapy to work with her to improve function. A family meeting is held, the patient and family verbalize their concerns, and a plan is made, including consideration of hospice services.

Once off of her Medicare skilled benefit, she is evaluated by hospice. The family agrees to take Mrs. L home, alternatives being to remain in subacute care with or without hospice (depending upon financing issues), or to go to a residential hospice. With family doing some of the nursing support at home and hospice providing its services, the patient has a pain-free death, entering a renal failure-related coma a week later and dying after five more days. Oral medications were discontinued. In the time that she was lucid, the family members were able to say their goodbyes and to have moments of tenderness and remembrance with their mother. Hospice provided bereavement support for a year after the patient’s death. Subacute care, in this instance, provided the bridge to home hospice.

Conclusion

Subacute care, occupying as it does the territory between hospital and home care, should look ahead to a future that includes a number of areas for expansion and development. These include: geriatric assessment, defining rational pharmacologic practice, and collaboration and coordination with palliative care, which have been discussed in this article. A fourth area for potential development, teaching programs for a variety of professional beneficiaries, will be discussed in a future article. The urgency around these potential developments arises because of two facts: first, demographic realities having an impact on the elderly and their families have not been matched by efforts in hospital care, community programs, funding or medical curricula; and secondly, subacute care is uniquely and elegantly poised to move in these directions. It should be the primary force in a movement to reclaim the initiative in healthcare for elderly individuals in the future.

The author reports no relevant financial relationships.