VENUES OF POST-HOSPITAL CARE Or “Where, Oh Where Will My Patient Go Next”? Ed Vandenberg MD CMD...
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Transcript of VENUES OF POST-HOSPITAL CARE Or “Where, Oh Where Will My Patient Go Next”? Ed Vandenberg MD CMD...
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)