The physician assistant (PA) profession is rooted in primary care; however, increasing numbers of PAs are choosing specialty areas. According to the 2018 American Academy of Physician Assistants’ salary report, 34% of PAs reported practicing in a hospital setting, whereas 56% remained in an outpatient setting (family and general medicine, internal medicine, pediatrics, and other specialty clinics or facilities). Although most medical care continues to be delivered in traditional settings, such as outpatient offices, ambulatory care centers, and acute care hospitals, there is a growing trend for care to take place in the patient’s home or in an initial posthospitalization setting. This trend is fueled by the aging “baby boomer” population, the need to decrease costs, and the personal desire of individuals to stay in their own homes. That home may be an individual domicile, congregate housing, assisted living facility (ALF), skilled nursing facility (SNF), nursing home facility (NHF), long-term acute care facility (LTAC), or hospice. Because of the rapid increase in demand for such services and ongoing changes in legislature, the need for PAs in nontraditional medical care settings is growing.
The goal of this chapter is to provide an overview of care delivery in a variety of settings and to help readers gain an understanding of patient options and the principles of the transition of care between facilities. Figure 46.1 , provided by The Hospitalist, gives an overview of the various facilities discussed in this chapter, and Table 46.1 provides an in-depth summary of these sites of care.
|Type or Site
|Inpatient rehabilitation facility
|Provide at least 3 hours of therapy per day; must make progress to continue
|Medicare, Medicaid, or private insurance
|SNF postacute hospital; needs therapy
|PT, OT, or speech; must progress to continue
|Medicare or private insurance
|Handle complex care such as ventilator patients
|Medicare or private insurance
|Home health care
|Nursing or therapy in the home; requires face-to-face encounters with a physician, NP, or PA
|Medicare, Medicaid, or private insurance
|May be in the home, NH, ALF, or inpatient hospice; avoids hospitalization; usual prognosis <6 mo; concentrates on comfort
|Medicare or other
|Home care or personal care
|ADL and IADL care in the home
|Varies but usually self-pay or Medicaid
|Chronically ill patients who are not able to benefit from rehabilitation and need nursing care
|Self-pay or private insurance; Medicaid
|Institutional care; may serve small or large numbers; services vary widely, and little regulation exists; patients are usually less disabled than in NHs
|Self-pay; few Medicaid
The “silvering” of the U.S. population is a well-established trend largely because of the aging of the “baby boomer” population. In the decade from 2020 to 2030, the population aged 65 and over is projected to increase by 18 million (from 56 million to 74 million). There is no doubt that this demographic shift will result in an aging “tsunami” of need for all kinds of care: medical, psychological, social, and rehabilitative. These needs will become an impetus for change in the U.S. health care system. Many patients will require postacute care (PAC) for ongoing medical needs, rehabilitation, and palliative care. Of the nearly 8 million people hospitalized in 2013, 22.3% were discharged to postacute settings. The transitioning of care to the appropriate setting for every patient is instrumental in maximizing the patient’s medical and functional recovery, regardless of age.
The PA training model emphasizes collaborative care and generalist training and thus equips PAs to readily take care of this fragile patient population. PAs play a pivotal provider role in all aspects of patient care, including management of active medical conditions, careful consideration of patient goals, functional implications of various medical conditions, communication with families and support staff, advocacy for patients, and facilitation of the transition of care in both inpatient and outpatient settings. Therefore it is essential to understand all components of the home health and postacute care medical systems in addition to the complex health care payer system. Most of the health care of older adults and disabled younger individuals is financed by Medicare, administered by the Centers for Medicare & Medicaid Services (CMS). Further information on reimbursement is provided in each section.
The term “informal caregiver” refers to an estimated 44 million unpaid family members and friends who serve as caregivers and are the largest source of long-term care in the United States. Although the monetary value of informal caregiving is difficult to assess, it has an estimated (unpaid) cost of approximately $306 billion annually, outweighing the annual cost of home health and nursing home care, which are estimated to be $115 billion. Caregivers’ tasks include instrumental activities of daily living (IADLs), such as handling finances, in addition to the performance of hands-on activities of daily living (ADLs), which include, but are not limited to, bathing, dressing, toileting, feeding, and mobility. Over the past decade, because of increasing numbers of care recipients with complex medical conditions, caregivers have found their roles shifting to include tasks usually considered medical or nursing-related, such as care of intravenous lines, injections, wound and ostomy care, and even management of home dialysis and ventilators. The majority of caregivers are middle-aged (35-64 years old) but many caregivers of older adults, especially spouses, are themselves elderly. Recent data, however, has found that one in four family caregivers is a millennial, with almost three in four having to balance full-time employment. Of concern, this population of caregivers is more likely to consume information at a higher rate but is less likely to seek out information from a health care professional. This may account for some of the frequent hospitalizations that occur in this group of high-complexity, high-needs patients and represents an untapped opportunity to reduce costs and increase caregiver and recipient satisfaction by providing more educational support.
As primary care providers, PAs can impart an invaluable service to their caregiving patients by helping them to optimize their health. A PA may be the only social and emotional outlet for an often-isolated caregiver. Recognizing and expressing appreciation of their efforts can be a positive incentive to continue in the role. Providing information on community support programs and assisting the family in locating respite may be important therapeutic interventions for both the care provider and recipient (see the Resources for recommended websites for caregiver support materials).
Home care organizations
Home care organizations (HCOs) include home health agencies, home care aide organizations, and hospice care. Most agencies are Medicare certified and provide skilled nursing assistance. Demand is on the rise and Medicare is the single largest payer of health care, accounting for slightly less than one-third of total payments. Other sources include private out-of-pocket payments, Medicaid, the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), and the Veterans Administration. Medicaid home care expenditures vary based on state eligibility rules and are oriented toward personal care activities such as bathing and dressing. It is essential as a provider to know your specific state’s rules. Managed care is another source of financing for home health, usually via a negotiated prepaid rate. Most contracts are through employer-based insurance, but it is also being used by some states in an attempt to reduce unsustainable Medicaid expenditures.
Of the patients who receive Medicare home health services, most have chronic diseases that impact their ability to perform ADLs. Common primary diagnoses include posthospitalization care, dementia, hypertension, heart disease (including congestive heart failure), chronic obstructive pulmonary disease, diabetes, osteoarthritis and musculoskeletal disorders, malignant neoplasms, and cerebrovascular disease. In general, recipients must have a skilled nursing need and meet Medicare’s definition of homebound (unable to leave the home without great difficulty; i.e., only leave the house for physician office visits or to go to church). Other providers such as physical and occupational therapists, speech pathologists, and wound care nurses are available without a skilled nursing need but require a provider order.
With the institution of the Patient Protection and Affordable Care Act (PPACA) in 2012, CMS now reduces payment to hospitals with excess readmissions. It has been suggested that outpatient home health visits by PAs can reduce the incidence of hospital readmission rates. It would be reasonable to conclude that there will be an increase in demand for home health visits by nonphysician providers in the foreseeable future.
Nursing home facilities
An NHF provides indefinite custodial care. Patients who reside in a NHF require daily nonmedical assistance with ADLs such as bathing, dressing, grooming, medication monitoring, mobility, and more. The facilities are usually funded via private payment from residents, but some are financed through state Medicaid programs and by charities. They may assist residents with medication management but are specifically prohibited from maintaining a medical director or skilled nursing services. Medical practices are reimbursed for visits made by PAs in nursing homes at 85% of the physician rate, provided the care is medically necessary. The participation of PAs in long-term care has been shown to reduce hospitalizations to a level even lower than that of community-dwelling Medicare recipients. The presence of a PA reassures nursing staff, patients, and families that a well-trained clinician is available to evaluate and manage patients’ symptoms.
House calls and the emergence of telemedicine
In the early 1900s, most physician services took place in the patient’s home, and diagnostic tools fit easily in the “doctor’s bag.” Gradually, improvements in transportation and technological advances led to centralized care in office-based practices, and house calls became a rare practice. In recent years, house calls have enjoyed a resurgence of popularity. Tangible benefits of house calls include a more accurate assessment of functional status and environmental safety, a closer relationship with patients and their families (reducing liability concerns), and a better understanding of the challenges faced by both patients and their caregivers ( Fig. 46.2 ).