Post-hospital sub-acute care: an example of a managed care model.

OBJECTIVE: This article describes Transitional Care Centers (TCC), an innovative sub-acute care program developed by a large managed care organization (HealthPartners in Minnesota) in partnership with five area nursing homes. The purpose of the TCC is to promote continuity of care for frail older members covered under a TEFRA risk contract. DESIGN: This is a retrospective study of the experiences and outcomes of enrollees who received TCC compared with a like group of enrollees who received customary continuity care through contract services. SETTING: The TCCs are established contractually in five area nursing homes; these facilities keep at least 15 beds available to the health plan for round-the-clock, 7 days per week admissions for sub-acute care. Designated staff from these facilities and designated geriatric nurse practitioners and geriatricians from HealthPartners follow established targeting, admissions, assessment, care planning, and discharge planning procedures to provide team care for these patients at the facilities. PARTICIPANTS: The TCC program is targeted to patients requiring rehabilitation therapy (post-cardiovascular accident, post-fracture/replacement) who are deconditioned, or those with uncomplicated infections (urinary tract infection, pneumonia). A total of 1144 patients participated in the TCC program in the 1-year program under report, and 253 were surveyed in regard to their experience. One hundred HealthPartners physicians were surveyed about the program. RESULTS: Post-acute length of stay in the TCC was substantially lower than that in customary care settings in contract nursing homes (14.3 versus 20.5 days). Rehospitalization rates from these units were comparable to or better than those from other sub-acute units. Patient and primary care physician satisfaction with the units was high. The program provided economic benefit to both partners. The health plan's negotiated rate for the TCC units was 38% less than that paid in noncontractual facilities. CONCLUSION: The TCC partnership provides rehabilitative and geriatric evaluation services in settings more conducive to and less costly than such care usually, and yields improvements in care and utilization outcomes.

Upper and lower airway disease in penicillamine treated patients with rheumatoid arthritis.

Four of 133 patients with rheumatoid arthritis suddenly developed progressive respiratory symptoms while receiving penicillamine therapy. None had previous disease. None of 89 patients treated with gold alone and 0 of 380 not taking gold or penicillamine developed respiratory symptoms. Two of the 4 developed simultaneous severe, unresponsive sinusitis. Lung biopsy demonstrated obliterative bronchiolitis (OB) in 2 patients, fibrosing alveolitis in one. A clinical course characteristic of OB was noted in the 4th patient. Sinus biopsy in 2 demonstrated lymphocytic and plasmacytic mucosal infiltration. The high frequency of OB in penicillamine treated patients and its absence in 469 non penicillamine treated patients suggests the possibility of a causal relationship.