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By MICHAEL SAMOGALA

In relation to health care in today's world and economy, many facets of health care go undefined and are not considered to be truly consistent with standards of quality operation and outcome.

Post-Acute Care (PAC) is defined by the governmental agencies as the rehabilitation or palliative services that individuals receive after, or in some cases instead of, a stay in an acute care hospital. Depending on the intensity of care the individual requires, treatment may include a stay in a facility, ongoing individual therapy, or care provided at home.

www.medpac.gov/-research-areas-/post-acute-care

After reading the above definition, we can conclude that anything that occurs after acute care services may be considered as post-acute care. This may certainly influence the decisions regarding discharge and continuation of care required by the individual after immediate or subsequent acute care services have been provided. We refer to these needs and this phase of care as transition. We must ask ourselves as health care providers why transition care and processes are so important to those we serve.

"The current process of care transitions for individuals with disabling conditions is both ineffective and inefficient. There is a need for clinicians with the necessary knowledge and skills to advocate and facilitate transitions that result in the greatest value to the individuals, their families, and the healthcare delivery system. A review of the literature reveals significant problems with transition to post-acute care (PAC) settings. Care is fragmented, disorganized, and guided by factors unrelated to the quality of care or individual outcomes." (Gage, 2009; Sandel et al., 2009).

As this statement communicates, the effects of fragmented care and services provided can and does affect the success and outcomes of those individuals needing and/or requiring complete post-acute rehabilitation services. We see these negative effects in all phases of the care continuum which include acute individual rehabilitation, skilled nursing facilities, the post-acute care arena and in the general community.

The negative results, and most importantly, formal outcomes of this, "fragmented care and services," for those individuals requiring post-acute rehabilitation care, include everything from multiple rehospitalizations to the acute and subacute areas of the care continuum. This may also include incarceration due to the symptoms of the initial injury and the behaviors that may accompany that injury which may be occult during the acute phase of hospitalization and recovery (TBI).

Transition to post-acute facilities includes preparation and validation of services provided, ideally outside of a pre-determined length of stay and progress parameters. Post-acute settings should focus on the individual and significant other/supportive care in relation to a rehabilitation process that includes, but is not limited to, a systemic comprehensive, multidisciplinary assessment in the development of realistic, measurable and functional goals.

In consideration of the multiple, specific, and often complex needs and barriers of this population, we are obligated to consciously validate and support facilities with accreditation and/or partnership status, reflecting the ability to provide all required services in the care of these individuals. Such accreditations/partnerships include, and may not be limited to, Commission on the Accreditation of Rehabilitation Facilities (CARF) (Brain and/or Spinal Cord Injury Specialty), Agency for Health Care Administration (AHCA), Brain Injury Association of America and United Spinal Cord Association.

In reference to the services provided at NeuLife Post-Acute programs, a CARF accredited brain injury and residential rehabilitation program, which primarily encompass neurological disorders related to acquired brain injury (traumatic and non-traumatic) and spinal cord injury, the importance of barrier focused rehabilitation cannot be overemphasized. The identification of barriers affecting the outcomes after discharge from any post-acute facility begin with the admission process which must effectively and accurately identify the specific needs and services the individual will require. This includes all domains of the multi-disciplinary professions that would perform in concert to achieve the most functionally safe, independent and progressive outcome. Examples of the effectiveness relating to a truly accredited post-acute program are proven in the outcomes which in our case indicate approximately 80% of catastrophic injured clients return home or to their communities.

The results of the admission process and assessment must be evaluated by the rehabilitation team prior to admission to any facility ensuring the consistency and quality of all services provided. The Post-acute rehabilitation team having the essential components of care and services coordination which include: rehabilitation specific case managers, physiatry services (rehabilitation specific MD), board certified rehabilitation nurses, neurology services, psychiatry services, neuropsychology services, cognitive, dysphagia and speech therapy, neurobehavioral and behavior plan with supports as needed, physical therapy, occupational therapy/functional independence team, mental health counseling and support - clients and family members and individual and family education and training.

It is our understanding as many such neurologic injuries and illnesses develop so does the extensive and often exhausting demands of caring for these individuals in a multitude of "post - acute" settings. This certainly leads all of us to realistically consider the financial impact of providing, what in some opinions should be, the universal standard of care. A publication citing the cost relationship between those individuals who were fortunate enough to receive comprehensive post - acute care as stated above actually proved to have more successful discharge outcomes (gains in functional status and level of independence) as well as overall financial cost savings over an extended period of time post injury. (COST/BENEFIT ANALYSIS FOR POST-ACUTE REHABILITATION OF THE TRAUMATICALLY BRAIN-INJURED INDIVIDUAL, M.J. Ashley, David K. Krych, Centre for Neuro Skills Bakersfield, CA Robert R. Lehr, Jr. Department of Communication Disorders and Sciences and Department of Anatomy, School of Medicine, Southern Illinois University, Carbondale, IL 1990).

In summary, post-acute accreditation, at its most effective level, not only includes, the maintenance and slow progression of an individual's medical stability, functional and cognitive ability, but also includes a process that focuses on the individual and personal needs and barriers as related to the client, his/her environment and the ability to adapt to any actual or perceived deficit. The responsibility to acknowledge and meet this challenge lies with all of us who provide care and services for these individuals beginning at the onset of injury or illness and ending with the most successful and functional outcome.

Michael Samogala RN, CRRN CBIS has been directly involved in providing professional nursing and education services to the healthcare community for over 40 years. Most notably receiving board certification in rehabilitation nursing and as a brain injury specialist, he continues to provide professional credited continuing education programs to multiple professionals across the country, and remains in the position of Director of Corporate Education, NeuLife Neurological Services.