Annals of Long Term Care

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.