The debate about dehospitalization has been attracting attention and gaining space in the health market in Brazil. The concept of home care is more intuitive and popular, but there is still a great lack of knowledge about transitional hospitals, their purpose and functionality. In an exclusive interview, Alexandre Santini, CEO of the Altana Network, shares more about this hospital model, the conditions served, the trajectory with the health operators, and his perspectives for the coming years.
Below are the main excerpts from the interview:
What are transition hospitals? What conditions are they useful for?
They are institutions that provide care for patients who have experienced an acute event and who are not yet able to return to their homes. We work through a multidisciplinary team composed of doctors, physiotherapists, occupational therapists, nutrologists, nurses, psychologists and social workers. We design a therapeutic plan with individual goals for each patient that enters our institution. These goals are set weekly and shared with family members, starting from the first moment of hospitalization. We aim to provide the patient with recovery and rehabilitation to achieve their maximum level of functional independence gain.
Hospitals dedicated to the care of acute patients focus on the diagnosis and stabilization of that patient, which involves a high investment in resources. The length of stay of patient care in this hospital today in Brazil is between four and five days. Let's imagine a patient who has had a stroke: he undergoes a moment of diagnosis, has a rapid intervention by a neurosurgeon, then he leaves the hospital and is in a stable condition with the sequelae caused by this acute event. The neurosurgeon's focus is not on caring for the patient after stabilization, but rather on treating the acute event. The focus of transition hospitals, on the other hand, is different. We are a multidisciplinary team focused on rehabilitating this patient. We still have patients with a high dependency on care in our institution, but in a lower critical condition than in the hospital. After we go through this phase, which can occur between 30 and 90 days, this patient is discharged. He often goes to his residence and family care in his new reality. Other times, he goes out for some other home care, which is aimed at less complex patients who do not depend on a doctor available 24 hours a day and a multidisciplinary team.
Basically, we work with three types of patients: the classic rehabilitation patient, who often has a good recovery and gains functional independence to return to their daily lives; the patient in palliative care, who is the one who is at the end of his life and this generates social distress for the family; and the long-term patient, who is the one in whom we tend to gradually decrease the level of care so that he can return to his home, improving his swallowing, removing tracheostomy, and other points.
We know that Brazil is very tied to health plans or SUS. How do you talk to these players? Are transition hospitals able to operate in the SUS today or not yet? And how does the conversation with health plans work?
We don't work with the SUS. It is a market that has not yet developed there, but I have the expectation that at some point this will happen. We are looking for a more benchmark for the American market, despite its peculiarities. We always look carefully at this market out there when setting up a business. We began to look at the patient who was institutionalized inside the hospital and who had a high degree of dependency and care. And then we started to be provoked, even by some hospitals, who pointed out that they didn't focus on reducing the complexity of institutionalized patient care.
We started and were able to be very successful in taking this patient who had been institutionalized in the hospital for three or four years and taking him to his residence. This patient came to our institution, we reduced the degree of complexity and were able to register many times for home care at first. And why didn't he go straight to home care before? Because he was a very unstable patient who went to home care and then needed readmission, and it was better to keep him in his own hospital. That's how our thesis started. Other companies here in the city of São Paulo started similar models, but looking more at cancer patients and palliative care, which was a different vision from ours.
We got closer to this market in the international context and began to evaluate the theses. The operator was afraid of taking the patient out of a hospital and falling into an experience with home care in which the patient never left that type of care, thus becoming a third player. There was a fear of the patient entering the transitional hospital and this becoming something long-term. So we created the decreasing compensation model: every palliative care or rehabilitation patient came here with a ticket and every period they had a decrease. When the initially established goal passed, that patient had a decrease that was no longer financially feasible for the company. We didn't do this because we didn't want the patient, but because in fact there was no need. Our thesis was based on the idea that “we accept this, we want to prove that we are aligned with you and that the patient comes to the transition hospital to really improve their clinical condition”. But that's a trajectory. Today we are coming up in 16 years. At the end of the last decade, starting in 2015, players from outside the city of São Paulo began to appear and they have helped us to spread this more widely in the sector. The operator continues to have the same pain. Throughout this period, we had a construction to prove faithful to our thesis. This has worked very well and we have been able to deliver what they expect. I can only speak for my company, but I would say that today the market welcomes us.
Is there a general number of how many patients we could take to a transition hospital that are not being taken today? And how much of a cost reduction have we achieved?
I can tell you a bit about my experience and the reality of São Paulo, which is where we operate. We are a daily cost reducer compared to our patient's daily hospital rate, which is chronic. Imagine: the patient with mechanical ventilation is normally inside an ICU, not in the bedroom. 60% of our patients are on mechanical ventilation, so I would say that there is between 70% and 80% reduction in the cost of hospitalization. It's hard to say about quantity, but we have the benchmarks. In the European market, for example, it is estimated that between 10% and 25% depending on the country, on the number of acute care beds. Imagine a country with 500 thousand acute care beds, you would have at least 50 thousand beds in transition hospitals.
In addition, it is worth noting that in Brazil we are experiencing a very large aging process. Over 70% of our patients are elderly. This was not because our focus is on the elderly, but because this population has a higher prevalence of diseases that have this impact. Then the growth is going to be very big.
Do you see dehospitalization as a health trend today? What about home care?
I believe that the tendency is for acute care hospitals to actually have a shorter length of stay and are increasingly focused on surgical centers, diagnosis and specialization. I believe that hospitalization tends to decrease and for this to happen there is a need to be more agile to discharge. But how will the market accommodate itself, whether there will be more transition or home care hospitals is another matter. I believe that the models are complementary and that, together, they promote value to the health system. Home Care is a consolidated and efficient solution, but with many opportunities, especially in the interface with the transition hospital. Home hospitalization occurred more in Brazil than abroad, but I don't know what the operators' vision will be like. But I think that there is a strong growth trend in transition hospitals due to their underutilization.
Do you have any tips for entrepreneurs? Where do you see the greatest opportunities?
There are some opportunities, but I think the main one would be the integration of platforms. This patient care navigation needs to be more integrated. The patient is always a new patient for each player in the health journey, who must design a new plan. When we think about chronic patients and the follow-up that needs to be carried out, integration is necessary. So I understand that this would be a very big gain in health and it's something we don't have yet.
