Medicare patients and alternatives to the acute care hospital

There are many instances where hospitalized elderly patients no longer need intensive hospital care but are not ready to be discharged. One solution to this dilemma is the use of a skilled nursing facility (SNF) or some type of step-down bed, where patients can continue to receive managed care at a less intense and costly level. A major concern with using step-down beds is that while costs may be controlled, quality of care may suffer and patient outcomes may be jeopardized. From an efficiency perspective, the step-down bed can provide an excellent alternative to hospital care for the less acutely-ill patient. For alternative managed care environments to be satisfactorily received by patients and physicians, however, they must produce outcomes equal or better than those in the hospital. Some patients and diagnoses are more appropriate than others for treatment in alternative managed care environments. The judgement of appropriateness must take into account patient and physician satisfaction with the efficiency and effectiveness of the care. This paper describes how the Fallon Community Health Plan, Worcester, Mass., which regularly uses a step-down facility for patient care, assessed outcomes in terms of efficiency and effectiveness. An overview of this alternative managed care facility and its relationship to the HMO is discussed below. Several studies examining outcomes and patient and physician satisfaction are presented. Finally, the ways in which these studies represent a merger of quality assurance (QA) and utilization review (UR) methodologies are discussed.