Post Acute Care for the Frail Elderly

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Post Acute Care for the Frail Elderly

• Steven Zweig, MD
• MU School of Medicine

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What is discharge planning?

• Identification of patient needs
• Creation of a care plan that addresses those
  needs
• Implementing the plan of care

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Why is discharge planning important?

• Hospital stay is brief window in the life of the
  patient what comes before and after is just as
  important.
• Frail elders especially are at risk.
• Poor planning results in failed care plans.
• Poor handoffs result in unnecessary readmissions.

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Determination of Patient Needs and Resources

• What is the patients functional and cognitive
  status?
• What are the patient/family preferences for goals
  of care and settings of care?
• What are the resources of the patient home
  assistance, social support, financial?

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Measures of Functional Status

• Instrumental Activities of Daily Living (IADLs)
• preparing meals
• shopping
• managing money
• using phone
• doing housework
• taking medications

• Activities of Daily Living (ADLs)
• bathing
• dressing
• eating
• toileting
• mobility
• transfer ability

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Dependency in one or more ADLs in Community
Living Elderly
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What is the appropriate care plan?

• What medical interventions must be carried out in
  the next phase (e.g. medications, IVs)?
• What is the most appropriate setting of care for
  the patients needs and resources?
• Who needs to be involved in developing and
  implementing that plan?

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Implementation of Care Plan

• Selection of post-acute care facility.
• Coordination of plans, transfer, and
  prescriptions.
• Communication with the next set of providers
  handoffs to phyisician, nurses, therapists, etc.

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What special planning needs arise in older
patients?

• Home situation those living alone may not be
  able to return after acute episode.
• Cognitive function delirium or underlying
  dementia are often not detected resulting in
  failed discharge plan
• Multiple chronic illnesses attention to
  dominant problem may complicate others

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Who helps with discharge planning?

• Importance of multidisciplinary teams working
  throughout hospital stay
• Physicians medical and cognitive function
• Nurses activities of daily living, medications
• Therapists functional abilities
• Social worker matching needs with resources

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How does discharge planning help family
caregivers?

• Often important to smooth transition to home or
  another setting of care
• Have special information about prior physical and
  cognitive status
• Needs must be considered work schedules, other
  family responsibilities
• Use community resources to facilitate family care

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Home Care

• Can be health related such as skilled therapies
  or nursing services (wound care, medication
  monitoring, etc.)
• Can be more social oriented such as assistance
  with instrumental activities of daily living,
  household chores, personal care

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The Home Care Neighborhood Companies, Services,
Payers and Consumers
Homemaker Services Personal Care Limited
Nursing Commonly called In-Home Major payer
Medicaid Consumer needs are usually long-term,
chronic
Homemaker Services Personal Care Nursing Other
services as needed Commonly called Private
Pay Major payer Private funds, Private
insurance Consumer needs determined by consumer
Nursing Care Personal Care Therapy Services--(PT,
OT, SL) Social Work Commonly called Home
Health Major Payer Medicare,
Medicaid Consumer needs are usually short-term,
acute care Physician ordered patient needs
intermittent skilled care and is homebound
A home care company may have one or all of these
types of programs. These programs have different
laws, rules, regulations and different
governmental agencies responsible for regulatory
oversight, licensing, inspections, surveys,
quality monitoring, etc.
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Physicians role in home care

• Must supervise and approve Medicare sponsored
  home care
• Must approve home oxygen
• Provide transition back to office based care
• Established historical role in home visits
• Help in assessment of care giver burden

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Current Status of Nursing Homes

• 33 largest chains 23 of all beds (4 are NFP)
• Expenditures 72 billion, Medicaid 47, Medicare
  8.2 - 40 billion
• 15,220 facilities, 1.66 million licensed bed,
  91.4 occupancy, 46 under 100 beds
• Medicaid recipients occupy 54 of NH beds
  
• 51.5 NH beds per 1000 people over 65 - down 2 per
  thousand (NY 42/1000, MO 70/1000)

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Demographic implications

• Of those over 85, 15 men and 25 women are in
  nursing homes
• During next 20 yrs those over 85 increase 5.5
  times the general population
• If 25 over 85 need nursing home care, NH will
  increase 76 in next 30 yrs
• If turn 65 in 1990, 43 some time 10 will have
  5 or more years

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Roles of the Nursing Home

• Custodial care
• Skilled nursing
• Special care units
• Rehabilitation - stroke, hip fracture
• Subacute care
• Hospice care
• Community center

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Who is at risk for nursing home care?

• Increasing age and frailty
• Mental, behavioral, or physical conditions that
  make community care difficult
• Functional disabilities that inhibit independent
  living
• Insufficient social support
• Short of available, affordable, community based
  long term care services

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How much does nursing home care cost?

• Average cost is 3000-4000 per month
• Total payments to nursing homes
• Medicare 3-5 - usually first 20 days
• Self-pay 42 - after Medicare runs out
• Medicaid 50 - after private funds run out
• Very small percentage from long term care
  insurance

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Staffing in nursing homes

• Every nursing home resident must have an
  attending physician most visit the facility 1-2
  times per month
• Director is RN most of the staff nurses are
  LPNs
• Most care provided by nurse assistants
• Facilities are chronically understaffed,
  turnover, burnout high

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Forces impacting nursing homes

• Increasing population of frail elderly
• Workforce shortage of physicians, RNs, CNAs
• Managed care - diversity, opportunity
• Investor expectations
• Limits in federal spending - social care vs.
  medical care
• Generations issues - two worker families,
  separation
• Competition from assisted living and home care

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Nursing homes are not the same

• Quality - inspections of care
• Staffing
• Medical care available
• Prevalence of ACD/DNR
• Dying

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Alternatives to nursing homes

• Within
• Social models of care- Eden Alternative
• Accredited subacute units
• Hospice care for dementia and others
• Outside
• Foster care - Oregon, others
• Assisted living
• Continuing care retirement communities
• PACE (Program All-inclusive Care of Elderly)

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Assisted living facilities

• Definition - varies state to state
• Top ten providers now control 30,000 beds, often
  former NH companies
• 1995 - 15 billion, 2000 - 30 billion
• Competition with nursing homes for small overlap
  population of low-acuity private pay patients
• Residents must be able to get out in case of
  emergency

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What is hospice?

• Hospice is unaffordable.
• Hospice is covered by Medicare, Medicaid,
  insurance and offer for uninsured.
• Hospice is for cancer patients only.
• Only about ½ are cancer patients.
• Hospice patients cannot see there regular
  doctors.
• These should continue to follow and bill under
  Part B, Medicare.
• Patients cannot disenroll when they want.
• False they can opt out at any time.

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Background

• Hospice is a multidisciplinary, patient-centered
  approach to palliative care
• Most dying patients want was hospice has to offer
  - home-based,comfort care
• Most dont know about hospice
• 50 die in hospital, 25 in NH, 25 home
• About ¼ of Americans receive hospice care

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What is hospice?

• Hospice care is guided by an individualized plan
  developed and implemented by a multidisciplinary
  team including attending physician, medical
  director, nurse care manager, social worker,
  chaplain
• Care plan consistent with preferences of the
  patient, including pain and symptom management,
  family and spiritual support

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What are the services provided?

• RNs provide direct care and case management
  visits as needed, 24 hr call
• Social worker assesses and provides support
• Chaplain provides pastoral care
• Medical director supplies oversight and
  consultation to team and physician

• Trained volunteers offer companionship
• Home health and homemaker services
• Bereavement care provided for one year
• Therapies as needed
• Physician and other consultations as needed

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What about drugs and equipment?

• These are provided as needed to address the
  hospice related condition
• Patient responsible for 5 co pay, not to exceed
  5
• Durable medical equipment such as commode chairs,
  walkers, hospital beds, oxygen supplied without
  charge

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Who is eligible for hospice?

• Anyone who is dying
• Medicare, Medicaid, and most insurers have
  hospice benefit paid as capitation
• Generally intended for those with life expectancy
  fewer than 6 months
• In 2000, 60 had cancer diagnosis, 80 Medicare
  recipients
• Guidelines developed for general conditions and
  specific diseases

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Do I give up care for my patients?

• The attending physician remains in charge of her
  or his patient while working cooperatively with
  the multidisciplinary team
• Important to collaborate based on goals of care
  as defined by patient, surrogate, and team
• FPs might get patients after subspecialty disease
  oriented care no longer beneficial
• Patients can be referred to other parts of care
  can be delegated

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How will hospice help me care for my patient?

• Dying patients and their family members need more
  help and attention
• First contact is hospice nurse, who is available
  or on call nurse is at all times
• SW and chaplain assessment and visits
• Regular team meetings review care plan and
  communicate with attending physician
• Services intensified at end, person to call,
  bereavement support

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How is hospice different from good home health?

• Share some of the same goals maintaining
  function and helping patient stay at home
• Home care patients are expected to stabilize and
  improve, and terminate when patient no longer
  merits nursing or rehab services
• Hospice does not require patient to be homebound
• Most hospice does not provide long term inpatient
  care (e.g. hospice house or hospital unit)

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If my patient is in hospice, does that mean I
cant treat pneumonia?

• No, but we need to compare every decision with
  the patients goals of care
• Goals shift from disease oriented to comfort and
  improving quality of life
• If treating pneumonia helps these, then ok
• May be terminal event that means patient should
  be supported with antipyretics, oxygen, and
  morphine

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What if my patient doesnt die within 6 months?

• This fear causes reluctance to refer patients
• Average length of stay in hospice was 48 days,
  median was 25 days
• 33 die within 7 days of referral making it hard
  to implement patients plan
• Patient reviewed at 3 mos and every 2 mos after
  for continuing eligibility
• No limit on length in hospice no risk of fraud
  for attending physician

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What if my patient wants to opt out, recovers or
doesnt need hospice anymore?

• Any patient can change goals of care and opt out
  at any time and then reenroll
• Hospice graduates are not uncommon patients
  who improve when disease oriented therapies are
  terminated

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What is things can be taken care of at home?

• Respite care can be provided for overwhelmed care
  givers
• Patients can be admitted for intensive management
  of symptoms
• Both are usually unnecessary

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What do we do in the hospital before hospice?

• Initiate discussions of goals of care
• Use the Comfort Pathway (look for these documents
  in Launch Applications in Power chart)
• Allow people do die in comfort in the hospital
• For those who do not need the hospital, involve
  hospice prior to discharge to enable smooth
  transition to home or nursing home

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What about hospice in the nursing home?

• 28 of deaths in Missouri occur in nursing homes
• No patient can receive Medicare sponsored SNF
  care and hospice (both Part A)
• Hospice can provide care in nursing homes
• Nursing home/ hospice must have contract
• Must share care planning
• New program to facilitate Guidelines for End of
  Life Care in Nursing Facilities (Missouri End of
  Life Coalition)

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How do I bill for hospice patient?

• Attending physicians bill same either office
  based or home codes adding GV modifier
• If unrelated to hospice dx use GW modifier
• Consulting physicians bill the hospice itself

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How to learn more about end of life care?

• Care for patients in hospice
• Participate in EPEC training
• Pocket manuals for symptom management
• Ask residency leadership for more talks!

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Summary for Post Acute Care

• Work well with team to assess, plan, and
  implement smooth handoffs
• Dont forget about communicating well with the
  people who will be taking over care
• Attend to the preferences of patients and the
  needs of caregivers to advocate for safe and
  effective care after discharge