VENUES OF POST-HOSPITAL CARE

Or

“Where, Oh Where Will My Patient Go Next”?

Ed Vandenberg MD CMDBill Lyons, M.D.

UNMC Geriatrics & Gerontology

Objectives

Upon completion the learner will be able to :• Describe best processes for appropriate and

timely discharge, placement and post-acute care

• List Medicare patient qualifiers for post acute venues of care

• Describe patient characteristics that will define appropriate placement post hospital.

PROCESS

• Review venues of care available for inpatients at time of discharge

• Review strategies and techniques to ensure timely and appropriate discharge.

At time of admission to hospital your elderly patient faces discharge to one

of the following:• Home with informal support• Home with Home Health Care• Skilled Nursing Facility (SNF)• Nursing Home care• Acute Rehabilitation• Long Term Acute Care Hospital• Hospice

Home with Home Health Care

Appropriate patient• consenting patients

whose medical needs can be safely managed at home when:

• The required time, financial, physical and emotional resources have been considered.

Medicare Qualifiers• reasonable and

necessary” for the treatment of an illness and injury”

and

• Requires Skilled Services

and

• HOME BOUND

How much service will Medicare pay for?

Services that are:

• part-time,

• intermittent,

• “skilled”

• Not “24/7 ” home care

Skilled Services• Registered Nurse• Physical therapist• Speech therapist

Other services may be added only if one of the 3 above skilled services are needed

Example:-Social work-Home health aide-OT

HomeboundThe Definition

Leaving home requires considerable and taxing effort.AndPatient needs:• supportive devices such as crutches, canes, wheelchairs

and walkersor

• the use of special transportation or

• the assistance of another personor

• if the condition is such that leaving the home is medically contraindicated

The Definition of Homebound-continued

Note: the HOMEBOUND can leave home if: • the absences from the home are infrequent *

or • for periods of relatively short duration

or • for the purpose of receiving medical treatment.

*Infrequent is often interpreted as once a week for non-medical outings)

• Medical outings can be often as needed and does not affect homebound status e.g. dialysis can be 3 or more times per week

Skilled Nursing Facilities(SNF)

Where provided:

• Nursing homes that are Medicare certified

Qualifiers:

• Hospital Inpatient 3 nights

• Moderately complex medical problem

Medicare pays for:

100 days

SNF Reimbursement– The nursing home determines eligibility for

Medicare benefits and assumes the financial responsibility if they determine the benefits incorrectly.

– Medicare pays 100% for the first 20 days and 80% for the remaining 80 days.

– 100 days of benefit is renewed when the resident has not been in a hospital or SNF for 60 days in a row and has now re-entered a hospital for 3 nights in a row.

Konetzka, et al. 2006 http://www.ohca.com/docs/medicare_coverage.pdf

Skilled Nursing Facilities

Moderately complexExamples:

• IV’s, IM injections• Feeding tubes• Dressing changes

(usually more than simple)

• Restorative care ( care and teaching by licensed nurse) (e.g care & training on: ostomy care, feeding tube care, wound care, etc.

• Rehabilitation

Skilled Nursing Facilities

• Services –SNF must provide: (required)– Rehabilitation services

– 24-hour skilled nursing services

Services that SNFs might provide: (not required)

– Memory support, Ventilator units, Subacute care

• HCP visits;

- Physician first visit within 30 days admit

- Physician/Mid-level alternate every 30 d x 3 then every 60 d.

Acute Rehabilitation HospitalsQualifiers:must be a Medicare certified facility. must require intense, multi-disciplinary rehabilitation supervised by a physician with experience or training

in rehabilitation medicine. (Physiatrist) care must be reasonable and necessary and not

available at a less skilled level of care.Patient requires & can perform ~three

hours of therapy each day • Licensed as a hospital • Rehab experts can focus on "real life" skills.

Acute RehabilitationHow to qualify?

QUALIFIERS• “RE-H-AB”mnemonic• Inpatient 3 nights

Examples; Immanuel, Madonna

• Re habilitatable?

is the patient reasonably expected to improve

• H elp?; will the treatment help?

• AB le; can the patient cooperate

• When in doubt, consult physiatrist

Long Term Acute Care Hospital (LTACH)

• Licensed as a hospital• Intensive nursing care and high-tech support• Medically unstable adults with complicated

injuries or illnesses.• LTACH is a “hospital within a hospital”. • This setting is reimbursed like any other

hospital but is specialized for the complex patient requiring extended care.

Long Term Acute Care Hospital (LTACH)

For: Medically complex• Clinical & ancillary support services on site

Qualifiers:• Expected LOS: 25 days or more• Pt’s condition requires;

– Frequent physician monitoring

– Highly Skilled level of care

Where in Omaha: “Select Hospital” “Select Hospital” (located near Bergan Mercy Hospital)

Long Term Acute Care Hospital

Examples Patient Types:Long term ventilatorsLong term parenteral antibioticsExtensive decubitus or wound careTPNNegative air flow room needsMultiple IV medicationsCombinations of > 4 treatments (e.g. Nebs, IV’s , wound care,)

Bottom line: Ask to see if person qualifiesAttendings: LTACH has list of physicians.

Nursing Home Care

Qualifier

Default (problems exceed home care, and does not qualify for any preceding venues of care)

Payment

Private or Medicaid or long-term care insurance

HOSPICE Services

• Goal: A good Death!

• Pain and symptoms management

• Psychological and spiritual care emphasized.

• Support system for caregivers before and after the death

• Hospice workers provide : intermittent, on-call 24/7 and occasionally short-term continuous home care.

HOME HEALTH HOSPICE Eligibility and Reimbursement

• Physician documents that the patient has six months or less to live

• Must have a caregiver available to provide care plan

• Medicare Part A, Medicaid, and most private insurances will have benefits for Hospice

http://www.nhpco.org

HOSPICE SERVICES

Interdisciplinary team • R.N.• Attending Physician• Hospice Medical Director (physician)• Chaplain • Social worker

HOSPICE SERVICES continued

• Bereavement for caregivers

• Volunteers• Durable Medical Equipment

such as a hospital bed, commode, special wheelchair, and other special assistive devices.

At time of admission to hospital your elderly patient faces discharge to one

of the following:

• Home with informal support-58%

• Home with Home Health Care 4.3%

• Acute Rehabilitation 1.7%

• Long Term Acute Care Hospital 0.2%

• SNF (Medicare covered)- 23.2%

• Nursing home care ( non Medicare covered) 3.5%

REVIEW of DISPOSITIONS

• Home with informal support

• Home with Home Health Care……………………

• Acute Rehabilitation….

• Long Term Acute Care Hospital ……………….

• Skilled Nursing Facility (SNF)…………………

• Criteria's

• Homebound

• >3 nights, RE-H-AB

• Complex, >25 days

• Mod complex, > 3 nights

Questions?

Next;

Review strategies and techniques to ensure timely and appropriate discharge.

What causes delays in getting patients to appropriate and timely

discharge?

-Complications of hospitalization

-Physician's “over estimation” of patients recovery abilities.

-Patient/family “unrealistic” expectations of recovery speed and level.

-“Last minute” planning

Physician's “over estimation” & Patient/family “unrealistic” expectations.

Realism vs UnrealisticOn or soon after admission:• “Plan for the worst and work for the best”• Discuss possible need for Home care or

Rehabilitation or LTAC hospital or even NH

Reduce “overestimation” errors by:• Knowing discharge dispositions available • Define discharge by Goals rather that Time

Define discharge by Goals rather that Time

• “Doctor, how long will I be in the hospital? ”

• TIME:• “Oh 2 –3 days”• Does not account for

post op complications or variations in patient response

• GOALS

• “everyone is different but here are the things you will have to be able to do before you leave”.

• #1 Medical &/or Surgical problems Stabilized

• #2 ADL’s appropriate for discharge disposition

ADL’s appropriate for discharge disposition

ADL’s & expectations

How to remember the ADL’s that will affect my patient?

D-E-A-T-H

• D ress

• E at

• A mbulate

• T oilet/Transfer

• H ygeine

• ADL needs and Placement

ADL Home

Care

Acute Rehab.

SNF LTAC

Hosp.

D ress +/- --- ---- ----

E at + + + ------

A mbulate + ------ ----- ------

T ransfer

T oilet

+ ------ ------ -----

H ygiene ------ ------ ------- ------

Reasons & Remedies for Delays in:Discharge per Social Work

• Late DC planning• Lack of knowledge

of:-Pt’s third party payer-Family and resources-Patient’s preferences

• Inadequate discussion of discharge planning

• REMEDIES• Early SW involvement

• Early SW involvement

• Disposition discussions by physician

“Last minute” planningREMEDIES

• Involve PCP early:

-Assist with coordination care.

-Knows the local systems & family better

-Knows the patient and can advise the patient/family on appropriate placement

Consult before Friday for weekend discharges to SNF or

NH or Home care• SNF: often won’t take on weekends unless

forewarned for staffing, medications, etc

• Home care: always dangerous to send home on weekends due to coverage by home care with out advance planning.

Review

Physician's “over estimation” of patients recovery abilities.

Patient/family “unrealistic” expectations of recovery speed and level.

“Last minute” planning

RemediesRealistic expectations

(add ADL’s to DC planning )

Introduce reasonable alternatives early

Involve SW & PCP early

END OF SHOW

• Questions?

• Additional References

www.hcfa.gov/medlearn/default.htm

• ( basic coding, assist with claims)