Question

This case involves two people. Both have been admitted to subacute cares units following stays in an acute hospital. However, they are different in many ways. As is the type of care they receive. They are used here to demonstrate some of the differences in the segment of the continuum known as subacute care.

David is 17 years old. He was injured in an automobile accident several months ago. Suffering multiple fractures and some internal injuries, he has been in a hospital for several weeks. While his initial injuries have largely healed, with the help of several operations, he still faces a long, difficult period of rehabilitation. It is for that rehabilitation, as well as monitoring of his overall conditions that he has been transferred to a subacute care unit.

Joyce is 67 years old. She has a long history of heart trouble and was admitted to the hospital following her last massive heart attack. That attack, coming on top of her already weakened heart condition, has left her in a semicomatose state. Her breathing is assisted by a mechanical ventilator, and she must be fed and medicated intravenously.

The subacute unit to which David was sent is known as a general subacute unit. It is operated by, and in conjunction with, a multilevel nursing facility. Joyce, on the other hand, was admitted to a chronic subacute care unit, operated by the hospital from which she was transferred. The difference between the two units is primarily the conditions they mostly treat and the kinds of staff and equipment needed to do what they each do best.

Both of them began their journey through subacute care with an assessment by multidisciplinary teams from the subacute units to which they were being transferred. Those assessments identified physical, medical, and mental conditions and developed individual care plans designed to best achieve the outcome goals identified for them. Because David appeared to be in need of physical rehabilitation, his assessment team was heavily weighted with therapists of one type or another, while Joyce’s assessment team was much more nursing oriented.

David’s outcome goal is to be able to return to his home and eventually back to school. The assessment team estimates that he will regain nearly all if not all of his previous functional independence. To achieve that, he requires intensive rehabilitation, including physical and occupational therapy. His care team is headed by a physiatrist and will focus on those therapies, although his medical condition will be watched.

Joyce’s prognosis is not nearly as bright. The team assessing her agreed that she unlikely to ever improve and sets a goal of maintaining her condition as well as possible until her death, something that is not likely to be that far distant. She does not need rehabilitation, although staff is the unit do some maintenance range-of-motion exercises with her to keep her physical condition from deteriorating. She does, however, require much more intensive nursing care and monitoring than does David and will be cared for under the watchful eye of a cardiologist.

Another difference, based on expected outcomes, is that David will receive close follow-up care after he is discharged to his home. He will probably continue some of his therapy on an outpatient basis and will be tested periodically to make sure he has not regressed in his quest for functional independence. Joyce, unfortunately, will not have that option.

While the probable results of their subacute care are expected to be so different, Joyce and David have a common reason for being transferred to those units. Their care needs are too high for them to be treated at lower levels, such as nursing facilities or at home. Yet, they do not need acute hospital care. A secondary, but very important, factor contributing to those transfers is the cost of care. David is covered by a managed care plan to which his parents belong. Joyce is eligible for Medicare. Both reimbursement sources want to give then them the best care they can, but at the lowest possible cost.

Thus, these two people in such different situations both find themselves in subacute units, between hospital and nursing facility care levels. It is a kind of care that suits them both well. Until only a few years ago, David would have stayed in the hospital for many months, at an unnecessarily high cost. Joyce might have remained in the hospital also, but because she was unconscious and was going to die prematurely due to her condition, it is more than likely that she would have ended up in a nursing facility unprepared to provide her with the care she needed.

Questions:

1a. What is a physiatrist? 1b. A cardiologist?

2. Is either patient a candidate for a living will or advanced directives? Who? and Why?

3. How can subacute care meet the needs of such different patients as David and Joyce?

4. Should both be included in a single care category, or should different levels of care be created for them?

5. In your opinion, is subacute care really a response to patient needs, or is it a way of increasing financing for providers?

Answer 1

1. A. PHYSIATRIST

Physician who specialised in physical medicine and rehabilitation is known as physiatrist.

B. CARDIOLOGIST

Doctor who specialised in cardiac medicine is known as cardiologist

2. - Yes.

- Joyce is a candidate for   living will or ddvanced directives,

- Joyce in a semicomatose state and on mechanical ventillator,she is not able to dicide or give consent on her treat

LIVING WILL

Living will and advanced directives are written legal instructions regarding the perfomance of medical care if the patient is unable to make decision. Advanced directive guide choices for doctor and care giver if the patient is terminaly ill,seriously injured or in a coma.

3  . Subacute care provide a specialised care to medicaly fragile patients,support their ability to carry out activities of daily living after an episode of illness.

For joice they cane give proper care on ventillator like suctioning,

Meet the nutritional needs like tube feeding

Bed sore prevention

Range of motion exercises

Prevention of DVT

Try to wean off and mobilisation

Medical Treatment

FOR DAVID they can provide

Proper rehabilitation

Meet nutritional needs

Limb physiotherapy

Walking exercises

Reassurance

Prevention of injury

Wean off to normal diet

Help to regain normal activity

4. We should create different levels of care for them,because

David is 17 years old young boy with good prognosis ,He will be alright after proper care, his team should include more specialised personals

Joyce is 67 yrs old ,terinaly ill ,semicomatose with poor prognosise.and she mainly needs nursing care services

5. Subacute cares are succesfully supporting idividuals to return their normal life,and do the activities of daily living,and rehabilitation.they can identify the patient needs and give proper care.