Comments on GeriPal - Geriatrics and Palliative Care Blog: Traversing the Great Divide: Inpatient and Outpati...

I think Helen is articulating a problem that needs...

2009-11-06T14:27:12.085-08:00

I think Helen is articulating a problem that needs to be given a lot more thought in Geriatrics. I think the rationale for viewing hospital medicine as a separate domain of expertise from outpatient medicine breaks down in frailer older patients.

More often than not, what dictates admission is not much related to the severity of the admitting diagnosis, but the factors that make it hard to care for the patient at home. For example, among patients with CHF, among those with the same severity of CHF exacerbation, there will be tremendous variability in who actually gets hospitalized. This is because it is often not the severity of CHF that dictates need for admission, but the comorbid conditions, frailty, caregiver stress, and cognitive impairment that necessitate admission. Every aspect of the inpatient treatment is really an extension of the chronic treatment. Unfortunately, more often than not the patient is treated just like another CHF exacerbation, and the really important stuff just gets ignored. We really need to be really careful about the siloization of inpatient and outpatient medicine.

Helen's and Eileen's accounts makes one wonder why it is so hard to make an exception to Medicare rules when it both saves money and is good for the patient.

I'd also be interested in the answer to Eileen's question. Exactly why is that the hospice wanted Helen's patient kept in the hospital overnight? Is that an ambulatory procedure gets paid for by the hospice out of their capitation, but a hospital admission for this procedure is not the financial responsibility of the hospice?

Two realistic examples of this great divide of inp...

2009-11-05T21:21:21.993-08:00

Two realistic examples of this great divide of inpatient and outpatient rules and regs. For a pt to have to be in the hospital 72h before Medicare will pay for a SNF does not save any money. In many cases, going directly to a SNF from home makes sense.

At the Veterans Hospital, we can bring hospice patients in for palliative procedure, such as the replacement of nephrostomy tube without interfering with the patient's Medicare Hospice Benefit because I don't think Medicare is billed for it (at least at this time). This does make hospices nervous and if that becomes the case, we have the VA pay for the home hospice. There must be a smoother bridge to meet the needs of these patients. In the private sector would that patient who had the nephrostomy tube re-inserted get billed for that hospitalization because Medicare Hospice Benefit wouldn't pay for it?

Great post. I actually think Accountable Care Org...

2009-11-04T21:48:55.606-08:00

Great post. I actually think Accountable Care Organizations(ACOs) could solve many of these problem with silos. What if we assigned a 30 day rehospitalizaiton to a community (ACO) rather than a hospital? Unfortunately, ACOs are complicated to explain and require a lot of communication between inpatient and outpatient practices.