case work

Transitional Care Units

This new care setting presents case managers
with a variety of unique challenges.

by Dale Mueller, EdD, RN, CNAA, NHA

THE TRANSITIONAL CARE UNIT, or TCU, is perhaps the newest care setting designation to earn distinction along the post-acute continuum. For case managers, TCUs can be one of the most confusing settings for assessing program appropriateness and favorable cost benefit analyses.

In simple terms, TCUs are designed to provide short-stay transitional care for patients who no longer need daily physician visits but wish to stay close to an acute hospital environment, where they can receive ancillary and nursing services at less cost than in an acute hospital bed.

But there's a lot more detail that case managers need to know about TCUs to make prudent choices for providers, insurers and patients. Since case managers have little formalized opportunity to learn the nuances of TCU licensing and programmatic requirements, there is a great opportunity for misinformation and misunderstanding regarding programs, placement criteria, cost and reimbursement, and overall contracting authority. By being aware of some of the possible variations, case managers can be much better prepared to gather the necessary details when investigating the most appropriate care arrangement for specific clients.

OPERATIONAL CRITERIA

To provide concise information for case managers, facilities should have clearly delineated criteria for TCU admission, including program specialties, population served, and purpose and goal of the TCU unit. For example, some TCUs provide medical or rehabilitative care under commercial managed care contracts only, and do not participate in the Medicare or Medicaid programs. Often, the purpose of these TCUs is to provide cost-effective care for patient outcomes when care is provided under a wrap-around case rate arrangement.

Other TCUs may fill their beds primarily with Medicare-covered patients. The October 1998 definition of transfer in regard to DRGs (Section 4407 of the Balanced Budget Act of 1997), will undoubtedly present these TCUs with significant management challenges. Facilities that will need to study care management strategies should work closely with case managers to determine the best placement for eligible Medicare beneficiaries needing a continuum of services following an acute hospital stay.

Still other TCUs serve special populations through designated program certifications under Medicaid. For example, a unit may specialize in weaning ventilator-dependent patients to prepare them for discharge to a long-term care setting, acute rehabilitation or long-term acute care setting. Or it may specialize in pediatric care, with the goal of discharge to home; or even young adult subacute rehabilitation in preparation for an acute rehabilitation regimen.

Contract management, risk designation and care outliers would be different for each of these units, even though they are all TCUs. To facilitate appropriate placement, facilities should supply case managers with current and easily referenced admission and discharge criteria, utilization review criteria for continued length of stay, typical patient profile and program offerings, and acceptable payer sources.

LICENSING REGULATIONS

Usually, the licensing category that applies to TCUs is that of an extended care facility (ECF), defined by Federal Conditions of Participation and the Omnibus Budget Reconciliation Acts of 1988 and thereafter. These regulations are often referred to as skilled care or nursing home regulations. Regulations and compliance applying to skilled nursing facilities, such as the minimum data set (MDS), RUGs III care level classification data, Medicare Part A coverage, ombudsman services, patients' rights to choose their own physician, and age- and gender-appropriate activity programs generally will apply to a TCU under skilled care regulations.

Case managers usually are not intimately familiar with the distinctions between regulations for acute care and skilled nursing facilities, leading to misunderstanding regarding which guidelines are mandated by regulation and which have been designated by providers. It is important for case managers to understand that if a rule is a facility's policy as opposed to federal regulation, it may be open to discussion. By determining what rules potentially may be changed, case managers may be able to negotiate for needed care and support.

REIMBURSEMENT ISSUES

The relationship of TCU and DRG reimbursement may also be confusing, because patients remain in the acute hospital following a DRG-covered acute stay. TCU placement is not covered under prospective DRG payment for an acute hospitalization, nor has it been an extension of a DRG-covered acute hospital stay. In the future, new definitions of qualified discharge and transfer may cloud this distinction, making it more difficult for case managers.

TCU Medicare reimbursement generally falls under Part A ECF inpatient benefits. Case managers may already be familiar with these eligibility and coverage requirements from transferring patients from an acute setting to a nursing home. But what may be familiar about Part A coverage--the need for skilled services, a three-day acute hospital qualifying stay, available days in the beneficiary's benefit period, and so on--will undoubtedly require additional considerations regarding cost and reimbursement for providers.

Currently, payment for transfers, as opposed to discharge, involve 10 designated DRGs, including DRG #14 (specific cerebrovascular disorders) and #210/211/236 (hip and femur procedures). Not only may this significantly affect the desirability and availability of TCU placement, but it also influences the clinical care pathways that case managers use to plan the continuum of services. *

Dale Mueller is director of the department of nursing continuing education at Learning Tree University, Chatsworth, Calif. Dr. Mueller is a licensed nursing home administrator with over 20 years' experience in post-acute care, and has been a national consultant in reimbursement and staff training in extended care.