Santa Cruz County is home to an intriguing health care mystery: The county spends much less on acute long term care than most of the country.
Santa Cruz’s long term acute care costs for Medicare beneficiaries is a little over 10 percent of the national average, according to preliminary data from the Centers for Medicare & Medicaid Services (CMS).
Long term acute care, or care for patients requiring ongoing medical care but who are not sick enough for a traditional hospital, costs $17 in Santa Cruz County on a per capita basis. The national average is $156 per capita, according to CMS, which is in the process of validating these numbers for communities nationwide.
Given the huge cost discrepancy between the county and the rest of the country, the state’s Medicare quality improvement organization is looking into what Santa Cruz is doing right – and if their practices could be replicated across the U.S.
The organization is collaborating with the Health Improvement Partnership of Santa Cruz County, which has created a study team of health-care providers and community members to get to the bottom of why this county accounts for such a small amount of Medicare long term acute care dollars.
A seemingly obvious answer is the county’s lack of a long term acute care hospital. These hospitals serve patients for 25 days or longer who have had a stroke, cardiac or breathing failure, spinal cord or head injury, a serious infection or other acute or chronic condition.
But some communities without long term acute care hospitals still have higher long term acute care costs than Santa Cruz, said Andrea Silvey, chief quality improvement officer of Health Services Advisory Group Inc. of California the state’s Medicare Quality Improvement Organization.
Patients in those regions are not necessarily getting better care than Santa Cruz residents, Silvey said. If patients were getting insufficient care, they would be landing back in traditional hospitals. That’s not the case in Santa Cruz.
Instead, the region had 30 percent fewer admissions than the national average in 2011. They also had 44 percent fewer readmissions 30 days after patients left the hospital, CMS reported.
One possible reason for the lower costs: The closest long term acute care hospital is an hour away from Santa Cruz, in San Leandro. The distance forces a deliberate decision to move a patient away from family and emotional support, said Dr. Robert Quinn, medical director rehabilitation services at Dominican Hospital in Santa Cruz. He suspects that’s a strong motivator for keeping sick family members at home.
Quinn has a patient in his 40s who is on a ventilator, he said, and his 80-year-old parents care for him. Other patients disabled by a spinal cord injury or stroke may need a ventilator, bowel and bladder care and feeding tubes, he added, but most of them don’t require 24-hour professional help. They need a limited amount of nursing care and physician oversight, but they could remain at home if a family member were able to do around-the-clock care. In-Home Support Services of Santa Cruz County pays family members just above minimum wage to do that, he said.
While few Santa Cruz Medicare beneficiaries are using long term acute care hospitals, they are using hospice and palliative care widely. Hospice is the only Medicare benefit where Santa Cruz surpasses the state and national average cost per Medicare beneficiary, CMS reported.
Hospice is a prime example of the support that exists in the community for families who choose to care for loved ones at home.
Linda Donovan’s family brought in Hospice of Santa Cruz County when her husband, Paul, suffering from cancer, wasn’t responding well to chemotherapy. They enjoyed a brief period when he got much better, and they had close to a normal life again, Donovan said.
Oxygen and medication were delivered, volunteers came to massage Paul and stay with him so Linda could leave the house. A chaplain counseled him, a social worker helped with the
administrative tasks and Linda received grief support. Paul died at home in May of 2006.
“If I didn’t have hospice, I wouldn’t have had that quality time with him,” said Donovan, who now volunteers her time to do grief support work for hospice.
“This community is doing a heroic job with hospice and advance directives,” said Dr. Lawrence deGhetaldi, president of Palo Alto Medical Foundation’s (PAMF) Santa Cruz division. And by intervening early with palliative care, people are living longer, he said.
Palliative care is provided by a team of doctors, nurses and others who work with a patient’s primary doctors to provide an extra layer of support for people with a serious illness.
Sharon Tapper, chief of staff at Dominican Hospital in Santa Cruz, established an out-patient palliative care pilot program in Santa Cruz in 2011. Medicare chose Tapper as an Innovation Adviser in January of 2012 for helping to move palliative care beyond hospital walls and out into the community where patients live.
Many candidates for long term acute care hospitals can live indefinitely. But for some it means a tough decision between getting some aggressive long-term acute care that will improve their quality of life for a brief time or calling in hospice or palliative care to ease pain and suffering for whatever time they have left. And it may be that patients and providers need to understand more about what these specialized hospitals offer to make an informed choice.
Certainly there is room for more education about these hospitals, said Kelli Cole, chief executive officer of Kindred Hospital-San Francisco Bay Area in San Leandro, the closest long term acute care hospital to Santa Cruz.
She wonders if patients are not being offered the opportunity to go to a specialty hospital because their health-care provider may not be knowledgeable about them, or the family may be resistant to the distance, she said.
“Maybe the patient could have longer quality of life if they were to go to a long term acute care hospital,” she said. “I’ve seen so many scenarios where a week into the stay the patient is off the ventilator.”
Cole envisions a time when long term acute care could become out-patient care, enabling more patients to use it.
It’s that type of innovation that Santa Cruz embraces as their changes to palliative care suggest.
“The community is made up of a lot of people willing to step into a leadership role to address issues in ways that may be different from the usual way,” Silvey said.