Part 3: Fiscal reality and length of stay
As I reflect upon the massive changes in health care in the last couple of decades, one of the most profound relates to our focus on length of stay and the ever-present need to reduce hospitals stays until they are so short I wonder sometimes how patients can be adequately treated in such short time frames. If we examine readmission rates, we find they have gone up and I wonder if they are proportional to the decreases in length of stay so we could assume an inverse relationship. Inevitably, this emphasis has found its way into long term care as fewer and fewer days are provided to residents, most of whom cannot fund their care out-of-pocket.
In some ways I wish we could return to an earlier model in which patients were kept in the facility until they were truly better. In other ways, I know this is not only impossible, it is undesirable. And, as the cost of care continues to escalate due to costs of medication, expensive technology, increasing salaries, etc., it would be impossible. In actuality, I think the quality of care has improved significantly as we are now required to be very attentive to how we use increasingly scarce resources. That has resulted in the need to provide patients with what they need when they need it and to reduce waste in terms of time and activities that do not make a difference.
Case management has allowed us to do this and to focus far more closely on the real needs of the patient. To this we have added our awareness and understanding that complete healing does not need to occur in acute care facilities; this has allowed the development of skilled nursing and rehab facilities, LTACHs, and other creative care environments, as well as an enhanced role for families in the care of their ill or injured member.
I remember years ago when my father had gall bladder surgery and was in the hospital for three weeks! Did he really need to be there all that time? No, of course not! And let us not forget the untoward consequences of overlong hospital stays...