Doctoring on the High Lonesome
Hopefully, you read Part 1 of this series, or at least skimmed it (rural health policy isn’t for everyone) for some background. In this post, I will dig into why critical access doctoring is different.
rural family medicine vs critical access medicine
What is the difference between “critical access medicine” and “rural family medicine?” Traditionally, rural family medicine practice was the “does it all” local doctor. The doctor who saw patients in his/her own practice, admitted them to the hospital, took ED call, delivered babies, etc.
I currently don’t have a practice and am not a reliable presence in the communities in which I work. I have no longitudinal relationship with patients. As such, I don’t really feel like I am doing “rural family medicine” in my current arrangement.
The bulk of what I do now is low acuity emergency medicine. Larger EDs label this kind of care “Fastrack.” However, I also have the occasional heart attack, stroke, sepsis, and trauma thrown in for sphincter training. In certain locations, I see the occasional primary care patient or urgent care patient in clinic. I also take care of low acuity acute inpatients. On top of all that, there is the bag of worms known as “swing bed” in Critical Access Hospitals (CAH).
The biggest difference between critical access doctoring and being an urgent care doctor, hospitalist, primary care doctor, or emergency room doctor is that I am often juggling all of these responsibilities at once. This demands a kind of mental flexibility and strategic thinking different from what I have experienced in more specialized settings. Moreover, you are almost always doing something at the limits of your comfort zone. You can call for advice (but rarely backup). At times, I am the only doctor in an area the size of Rhode Island.
swing bed programs
Swing bed programs are designed to allow CAHs to “swing” some of their unused beds into post-acute care skilled nursing facility (SNF) beds. CAHs most often use these for post-stroke, acute illness, or surgical rehabilitation services. These services include: physical therapy, occupational therapy, speech therapy. Occasionally, patients who require long term treatments such as IV antibiotics are swing bed patients.
The purpose of these programs is to allow CAHs another revenue stream to help them maintain their critical access mission. The reimbursement for this is again “cost based.” No hospital will be able to make a profit with swing bed services. However, they can get a lot of the costs covered that a hospital incurs from having nurses, techs, doctors on call or on the payroll just to have a basic level of service.
why can’t people just stay in the hospital?
Normally, swing bed patients are fairly easy to care for. The acute care hospital (ACH) addressed their acute issues and it should be fairly simple from that point on. In fact, the doctor only has to see them every 7 days, because they are not supposed to need acute care. However, it is not rare for the transferring acute care hospital to present the situation in the rosiest light possible.
These patients are often chronically ill and debilitated and on government insurance such as Medicaid and Medicare. These plans pay based on DRGs (diagnosis related groups). Meaning, for a given diagnosis, CMS pays an amount based on the average cost of providing care for the diagnosis.
So, once the ACH has dealt with their acute diagnoses, these patients are costing them money. Especially if they are short of staffed-beds and having to turn away other acute care patients. They want them gone.
swing bed can be a solution
In the past, these patients might just be sent home or out onto the street by some of the more profit-hungry hospital systems. If they came back, no worry, CMS paid them for the second hospitalization as well. Now, hospitals are getting penalized for 30-day readmissions.
Due to these new punishments, acute care hospitals want to get patients out of their hospital, but to somewhere from which they are unlikely to bounce-back – SNFs(skilled nursing facilities), LTACs (long term acute care), LTCFs (nursing homes, assisted living, etc). Basically, swing bed programs allow CAHs to function both as an acute care hospital and as a SNF.
This financial pressure on acute care hospitals means that sometimes the transferring hospital buffs the chart to make the patient seem less sick than they are. It definitely happens where a patient arrived at the CAH, spent 1-2 nights, and quickly return to the ACH because of their illness acuity.
trials and tribulations of a swing bed patient
Specifically, I can think of a patient who had back surgery, was in the surgical hospital for 3 nights, then sent home. She presented to our ED with worsening pain and inability to care for herself at home. Due to her first hospitalization, she qualified for swing bed. I admitted her to swing bed as there was no obvious acute diagnosis at the time.
Her pain worsened, she developed a fever, which in the end turned out to be secondary to a wound infection. She returned to the acute care hospital for a washout and antibiotic treatment. She was sent back to our facility for IV antibiotics and physical therapy. 3 days later, her wound was gushing with fluid again. Back she went to the acute care hospital for another washout and treatment, after which the acute care hospital transferred her to an LTAC.
critical access doctoring
I spent a disproportionate amount of time on swing bed care because it is a type of medical care that really only exists in CAHs. It is definitely NOT what I spent the majority of my time doing, but it is something that I had never encountered before working in a CAH. It took me a while to wrap my head around it. I have even hospitals that utilize swing beds often poorly understand it. I hope that the discussion was useful for anyone who is trying to figure it out.
Finally, I hope this paints a basic picture of critical access medicine. At its foundation, it is a commitment to meeting patients where they are, in a literal and geographic sense. The challenge is that there is almost no routine and you are frequently reinventing the wheel. This necessitates lower volumes as you have to think things over more carefully and can’t rely on muscle memory and reflex. If you can handle those constraints, the benefits are more time with patients and more variety than almost any other practice environment.