Sports Medicine and Rehabilitation Bradenton FL & Parrish FL - Sports Medicine physician Florida USA

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Subacute Care

Viewpoint of Subacute Care


There is an increasing movement to provide intensive medical and rehabilitative services in the skilled nursing setting. Over the past ten years, this service delivery extension became an  identity: subacute care.  Subacute care is an industry term. Since there are no distinct bed licensure or reimbursement systems in place, subacute is frequently misunderstood.  In the rehabilitation model, subacute is becoming a viable competitor.

For the medically complex patient, subacute has become the natural continuum of service delivery.  Historically, as far back as 1981, the staff of the Office of Research at HCFA argued that most stroke rehabilitation patients should be treated in subacute rehabilitation programs rather than in community hospitals.

However, it was the managed care payor who established the subacute provider in the healthcare industry, not the government.

With the recent exponential growth of subacute care, especially within the skilled nursing facilities, there are many opportunities for physicians to assume a medical director's position. A physician who chooses a medical director's role faces both administrative and clinical challenges. In addition to providing individual patient care, the role of the medical director also demands that he/she serve as a liaison between the administration, the governing body, and the entire professional staff. 

The medical director's duties include participating in policy making and long-range planning. The director should supervise the development of guidelines, rules and regulations for attending physicians, consultants, dentists, and allied health professionals.

The director should establish standards of medical practice and be able to supervise and coordinate medical care by peer review. The director should also be available to provide emergency medical coverage in the absence of the attending physician or his'J1er designee.

  The medical director serves on patient care policy, admissions, infection control, pharmacy, safety, interdisciplinary, and budget committees.  If the director is an employee of the skilled nursing facility, he/she may not be a member of the utilization review committee, but can serve as a valuable resource person. As a consultant or independent contractor, he/she may serve on the utilization review committee.

His/her role is to advise administration regarding the need and adequacy of medical equipment and supplies such as to ensure quality medical care.  Skilled nursing facilities have certain strict regulations based on federal and state legislation. The medical director cannot be considered the chief of the attending physicians. Rather than direct the attending physicians, the medical director gives them guidance and advice. 

Attending physicians may strive for autonomy, but the medical director must direct conformity to patient care policies. This relationship has to be a negotiated one, characterized by tact, diplomacy, and a professional mutual understanding.  In reality, the medical director represents administration and has a mission to see that quality care is delivered.  The skilled nursing facility may have an open or closed medical staff.

In an open medical staff, any physician with a state license to practice medicine is entitled to admit patients to the facility in accordance with the facility's admission criteria. In an open medical staff, the medical director should develop written guidelines to delineate the attending physician's responsibilities.

These policies should be approved by the governing body before they are implemented.  The medical director is responsible in scheduling regular medical staff meetings in order to provide information and direction to the entire medical staff. 

In a closed medical staff, the governing body appoints physicians on the recommendations of
the medical staff's credentialing committee. In a closed staff, only members of the medical staff have admitting and treating privileges. As few as three physicians may constitute a closed medical staff according to the joint Commission on Accreditation of Hospitals. In order to have a closed medical staff, it should be in the policies and bylaws of the governing body and medical staff. 

The advantages of a closed medical staff are that it allows for better communication between the interdisciplinary teams and greater continuity of care. These physicians are chosen based on their professional expertise and their commitment to provide both quality medical and rehabilitative services for the patients. 

Community physicians are frequently invited to continue visiting their patients within a closed medical staff and can be provided courtesy, temporary or consulting privileges.  Ultimately, it is the closed medical staff of the facility who has the responsibility for the patient's care.  Regardless of an open or closed medical staff, all physicians who apply for staff privileges should be of good character, graduated from an approved School of Medicine, and are currently licensed to practice in the state.

The appointment of physicians must follow a procedure outlined in the bylaws of the medical staff. Nominations should originate from the president of the medical staff and should be made in the form of a written application. This application must be accompanied by a signed statement that the nominee agrees to abide by the medical staff's bylaws, rules, and regulations.

Once approved by the medical staff and the president of the staff, the application is referred to the governing body for approval. The governing body appoints and reappoints members of the medical staff annually, subject to the medical staff's approval. 

The medical director must be familiar with federal, state and local codes, and regulations that are applicable to skilled nursing facilities.  Additionally, the medical director should be familiar with accreditation bodies such as the Joint Commission on Accreditation of Healthcare Organization UCAHO) standards for skilled nursing facilities, and the Commission on Accreditation of Rehabilitation Facilities (CARF) standards for the subacute medical and rehabilitation programs that became available in January 1995. 

As healthcare reform continues to redefine service delivery systems and as managed care drives the costs lower, subacute care establishes itself as a viable alternative for patient care. As the subacute industry grows, the opportunities for physicians desiring a medical director's position become more available.


Should you have any further questions regarding this article, please direct your questions or comments to "Ask the Doctor" section.


Copyright © 2004 - 2012Taras V. Kochno, M.D.  All Rights Reserved
Board Certified in Physical Medicine and Rehabilitation









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