Post-acute care generally refers to a system of care that provides health, social and other supportive services to incapacitated seniors and people with disabilities. Often referred to as “continuing care”, it is most commonly delivered at different levels of intensity ranging from in-hospital rehabilitation to long-term care, supportive/assisted living settings and finally home care. In general, this care is provided by a mix of public and private operators. Post-acute care terminologies and the provision of services at different levels of intensity differ across the provinces, impeding the ability to make any pan-Canadian characterizations.
Funding post-acute care
Though well-developed internationally, funding policies aimed at improving the efficiency and quality of post-acute care are relatively undeveloped in Canada. In general, the remuneration of post-acute care is divided between the provision of health care services and accommodation (though clearly this latter category does not apply to home care). These are often paid for through a mix of public and private funds (including private insurance or out-of-pocket), either on a global budget basis or on a per patient basis.
Under the current funding policies, the different levels of post-acute care largely operate in isolation from one another, acting as separate silos of care. This creates a fragmented system, one that is associated with numerous inefficiencies and limitations (Ontario Ministry of Health & Long-Term Care 2010). Nor do the current funding policies create financial incentives for post-acute providers to ensure that the care they deliver is timely or at the appropriate intensity. We have described the current basis for funding rehabilitation, long-term care, and home care in Canada, separately.
Several different funding mechanisms exist that may offer policy makers solutions to improving post-acute care. These mechanisms reward the coordination and continuity of care across acute and post-acute providers and offer potential for adaptation in Canada. These are reviewed for rehabilitation care, long-term care, and home care.
Challenges of funding reform in post-acute care
Clinical guidelines
There is little in terms of scientifically-based guidelines substantiating the treatment protocols and the intensity level of care needed to appropriately care for patients after discharge (Colla et al 2010). This makes it difficult to develop rigorous metrics required to carry out evaluation and performance assessments of post-acute care. Consequently, while patients may be safely cared for in a variety of settings, their level of care is not always optimized to their needs (Sutherland & Crump 2011).
Data
The success of any funding reform hinges on the availability of timely and reliable data. Data surrounding the provision of post-acute care varies considerably by level of intensity and by province (Ontario Ministry of Health & Long-Term Care 2010). Gaps in standardized data make it challenging for policy makers and administrators to make informed decisions.
The challenges associated collecting these data should not be underestimated. Given the mix of public and private providers; the lack of standardized set of measures (whether clinical, process, quality measures or otherwise); the various silos created by different levels of care intensity; and the various electronic platforms each post-acute provider uses. Each of these issues adds to the complexity of constructing the data needed to derive funding policies to promote efficiency and project population needs into the future.
The importance of aligning financial incentives across sectors
Under the current post-acute funding mechanisms, there may be disincentives for discharging or transitioning the least costly patients, preventing patients who require this level of care from accessing it. This problem could be aggravated with the funding reforms in acute care currently underway in Canada. The activity-based funding (ABF) policies being implemented in some provinces will increase hospital volume; but for this to be effective, the post-acute system must have the capacity to deal with this increase in volume. Failing to do so would lead to inefficient resource utilization and and, likely, an increase in alternate level of care (ALC).
