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VENUES OF POST-HOSPITAL CARE

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VENUES OF POST-HOSPITAL CARE Or Where, Oh Where Will My Patient Go Next ? Ed Vandenberg MD CMD Bill Lyons, M.D. UNMC Geriatrics & Gerontology – PowerPoint PPT presentation

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Title: VENUES OF POST-HOSPITAL CARE


1
VENUES OF POST-HOSPITAL CARE
  • Or
  • Where, Oh Where Will My Patient Go Next?

Ed Vandenberg MD CMD Bill Lyons, M.D. UNMC
Geriatrics Gerontology
2
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.

3
PROCESS
  • Review venues of care available for inpatients at
    time of discharge
  • Review strategies and techniques to ensure timely
    and appropriate discharge.

4
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

5
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

6
How much service will Medicare pay for?
  • Services that are
  • part-time,
  • intermittent,
  • skilled
  • Not 24/7 home care

7
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

8
Homebound The Definition
  • Leaving home requires considerable and taxing
    effort.
  • And
  • Patient needs
  • supportive devices such as crutches, canes,
    wheelchairs and walkers
  • or
  • the use of special transportation
  • or
  • the assistance of another person
  • or
  • if the condition is such that leaving the home is
    medically contraindicated

9
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

10
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

11
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/me
dicare_coverage.pdf
12
Skilled Nursing Facilities
  • Moderately complex
  • Examples
  • IVs, 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

13
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.

14
Acute Rehabilitation Hospitals
  • Qualifiers
  • 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.

15
Acute Rehabilitation How to qualify?
  • QUALIFIERS
  • RE-H-ABmnemonic
  • 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

16
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.

17
Long Term Acute Care Hospital (LTACH)
  • For Medically complex
  • Clinical ancillary support services on site
  • Qualifiers
  • Expected LOS 25 days or more
  • Pts condition requires
  • Frequent physician monitoring
  • Highly Skilled level of care
  • Where in Omaha Select Hospital
    Select Hospital (located near Bergan Mercy
    Hospital)

18
Long Term Acute Care Hospital
  • Examples Patient Types
  • Long term ventilators
  • Long term parenteral antibiotics
  • Extensive decubitus or wound care
  • TPN
  • Negative air flow room needs
  • Multiple IV medications
  • Combinations of gt 4 treatments (e.g. Nebs, IVs ,
    wound care,)
  • Bottom line Ask to see if person qualifies
  • Attendings LTACH has list of physicians.

19
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

20
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.

21
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
22
HOSPICE SERVICES
  • Interdisciplinary team
  • R.N.
  • Attending Physician
  • Hospice Medical Director (physician)
  • Chaplain
  • Social worker

23
HOSPICE SERVICES continued
  • Bereavement for caregivers
  • Volunteers
  • Durable Medical Equipment
  • such as a hospital bed, commode, special
    wheelchair, and other special assistive devices.

24
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

25
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
  • gt3 nights, RE-H-AB
  • Complex, gt25 days
  • Mod complex, gt 3 nights

26
Questions?
  • Next
  • Review strategies and techniques to ensure timely
    and appropriate discharge.

27
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

28
Physician's over estimation Patient/family
unrealistic expectations. Realism vs Unrealistic
  • On 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

29
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 ADLs appropriate for discharge disposition

30
ADLs appropriate for discharge disposition
  • ADLs expectations
  • How to remember the ADLs that will affect my
    patient?
  • D-E-A-T-H
  • D ress
  • E at
  • A mbulate
  • T oilet/Transfer
  • H ygeine

31
  • ADL needs and Placement

ADL Home Care Acute Rehab. SNF LTAC Hosp.
D ress /- --- ---- ----
E at ------
A mbulate ------ ----- ------
T ransfer T oilet ------ ------ -----
H ygiene ------ ------ ------- ------
32
Reasons Remedies for Delays in Discharge per
Social Work
  • REMEDIES
  • Early SW involvement
  • Early SW involvement
  • Disposition discussions by physician
  • Late DC planning
  • Lack of knowledge of
  • -Pts third party payer
  • -Family and resources
  • -Patients preferences
  • Inadequate discussion of discharge planning

33
Last minute planning REMEDIES
  • 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

34
Consult before Friday for weekend discharges to
SNF or NH or Home care
  • SNF often wont 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.

35
Review
  • Physician's over estimation of patients
    recovery abilities.
  • Patient/family unrealistic expectations of
    recovery speed and level.
  • Last minute planning
  • Remedies
  • Realistic expectations (add ADLs to DC planning
    )
  • Introduce reasonable alternatives early
  • Involve SW PCP early

36
END OF SHOW
  • Questions?
  • Additional References
  • www.hcfa.gov/medlearn/default.htm
  • ( basic coding, assist with claims)
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