LTAC Discharge Timing Focus

LifeCare Physician - Volume 3, Issue 1, Q1 2015

05.07.15
On February 18, the Wall Street Journal (WSJ) published an article on the timing of long term acute care (LTAC) patient discharges. The analysis revealed more patients are discharged during the “three-day window” surrounding the patient’s expected discharge date – based on their diagnostic related group (DRG) – than at any other time.

The WSJ also seemed to infer that financial considerations could be a motivating factor for the clustering of discharges around the expected DRG-driven discharge date because that is when hospitals receive full reimbursement for that particular diagnosis. Specifically, the WSJ noted 26 percent of Kindred LTAC patients and 30 percent of Select Medical LTAC patients were discharged
within three days of the expected discharge date, based on their DRG. LifeCare was not asked to comment and was not mentioned in the article.

As physicians know, the expected discharge date for a patient is based on the specific DRG for each individual case for both short term acute care (STAC) and LTAC hospitals. The expected length of stay (LOS) for any DRG in either setting is determined by the geometric mean of the historical LOS for all patients with that particular diagnosis or DRG.

Given this fact, it should be no surprise the statistics show that discharges are clustered around the DRGderived expected discharge date – because that is precisely how the DRG-expected discharge date is determined. To put it simply, if historical records over many years show
the average LOS for a particular DRG is “X” number of days, it is only logical that a typical patient with a typical hospital course would likely be clinically ready and safe for discharge after approximately “X” days.

Reimbursement is tied to these DRG-based LOS criteria to ensure the patient receives the clinical care and time needed to recover. If the patient recovers more quickly than expected they are deemed a “short stay” and the reimbursement for their care is adjusted appropriately downward to reflect that shorter LOS.

If the patient recovers in approximately the time allotted by the historically based DRG, reimbursement is made at the LTAC rate. Again, remember the geometric mean LOS for prior patients with that same DRG determines the expected discharge date.

This DRG-based expected LOS and reimbursement system has been in place in LTAC hospitals for more than a decade and in STAC hospitals for many decades. The expected LOS based on this system is not a mandatory “target” but simply a historically based guideline for similar patients.

We are all aware no patient should ever be discharged until they are clinically stable, safe, and appropriate for a change in their level of care. Physicians, nurses, therapists, social workers, and case managers must – and do – work together to ensure the timing of each and every discharge
is indeed appropriate for that particular patient.

The WSJ commented that approximately a quarter of all LTAC patients are discharged during the three-day window around their DRG-based date, but that also means approximately three-quarters of patients are not discharged during that time period. The fact that approximately 75 percent of LTAC patients do not leave the hospital during the most financially beneficial time period for the hospital points to the fact that patient stays are being managed based on the clinical needs of
individual patients.

No specific discharge date can nor should ever be decided ahead of time for any patient. Providing the very best clinical outcome in a safe environment with a smooth transition to the discharge destination has been and will always be our goal for each and every one of our patients. This is only possible through truly individualized care – no two patients are alike.

Our superior clinical outcomes speak for themselves, and our excellent clinical teams, including our outstanding physicians, are able to achieve these successes only by recognizing the unique nature and specific needs of each of their deserving patients.