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Circle of Care. October 30, 2012. Medicare Payments In 2010. (Percentage) (Dollars in Billions) Inpatient Hospital 39 130 Physician Services 29 96 Outpatient 14 46 Skilled Nursing Facility 8 26

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Circle of care

Circle of Care

October 30, 2012


Medicare payments in 2010
Medicare Payments In 2010

(Percentage) (Dollars in Billions)

  • Inpatient Hospital 39 130

  • Physician Services 29 96

  • Outpatient 14 46

  • Skilled Nursing Facility 8 26

  • Home Health Agency 6 20

  • Hospice 4 13

  • Total 2010 Medicare Expenditures:331 Billion


Program goals
Program Goals

  • Reduce preventable hospital readmissions

  • Safe transition from SNF to home

  • Provide lower cost, high quality alternative to acute care setting

  • Provide patient-centered care


Snf rules of participation
SNF Rules Of Participation

  • Part A (Hospital Insurance)

  • Qualifying Hospital Stay – Inpatient hospital stay of 3 consecutive midnights

  • Doctors orders for skilled services

  • Skilled care required daily

  • Up to100 day episode of care


Medicare snf qualifying 3 day in patient hospital stay
Medicare SNF Qualifying 3-Day In-Patient Hospital Stay

Required for traditional Medicare Fee For Service under Part A

  • Exceptions:

    • Medicare Advantage (Part C)

      • Tufts, Fallon, Blue Cross Blue Shield, etc.

    • PACE-Program of All Inclusive Care for the Elderly

    • SCO (Dual Eligible)-Senior Care Options

    • MGH Waiver Program


Sensitive admissions
Sensitive Admissions

  • UTI

  • Dehydration

  • Pneumonia

  • COPD

  • CHF

  • Diabetes

  • Hypertension


Home health care rules of participation
Home Health Care Rules Of Participation

  • Part A (Hospital Insurance)

  • Services provided under a plan of care established & reviewed regularly by a physician

  • Require one or more of the following

    • Skilled nursing care less than 7 days/week

    • PT, OT or ST

  • Certified homebound by physician

  • Up to 60 day episode of care; 30 day window


Home health care services not covered by medicare
Home Health Care-Services Not Covered By Medicare

  • 24 – hour-a-day care at home

  • Meals delivered to home

  • Homemaker Services

  • Personal Care (bathing, dressing and using the bathroom) when this is the only required care


Successful home health care progams
Successful Home Health Care Progams

  • Communicate with Skilled Nursing Facility and PCP

  • Provides Consistent Care Givers

  • Telemedicine – Early symptoms recognition and monitoring


Frequent causes of rehospitalization
Frequent Causes Of Rehospitalization

  • Mismanagement of medications

  • Moderate to severe functional impairment

  • Inadequate patient/family education

  • Lack of family safety net

  • Comorbidities

  • Patient reluctant to allow care givers in home

  • Failure to keep follow up appointments

  • Poor diet, insulin management

  • Substance abuse


Keys to safe transition home
Keys To Safe Transition Home

  • Discharge planning starts on admit date

  • Communication with patient, family, PCP and home health agency

  • Care management meetings with patient, nursing, therapy and case management

  • Discharge meeting with home health care

  • Family and Patient education

  • PCP notification – medication, lab, pending tests and any special needs

  • Electronic medical records


Life care discharge planning
Life Care Discharge Planning

  • C.O.A.C. H.

    • Communicate Expectations

    • Organize goals

    • Assign coach

    • Continued review

    • Handoff homework


Snf home health care agency coordination of care
SNF/Home Health Care Agency Coordination Of Care

  • Home Health Care Agency (HHCA) Case Manager

    • Reviews patient chart w/SNF Interdisciplinary Team (IDT)

    • Attends Discharge Planning Meeting at SNF

    • Coordinates required services (Nursing, Therapy, etc.) with IDT

      SNF Case Manager

    • Schedules Home evaluation

    • Orders DME

    • Provides education to family care givers


Snf home health care agency coordination of care1
SNF/Home Health Care Agency Coordination of Care

  • Conducts follow up calls with patient/family (within 48 hours)

    • Seek feedback-How patient is succeeding at home

    • Follow up on patient concerns

    • Provide over the phone education

    • Assist in providing additional/services if needed

    • Readmit to facility within 30 days (3 day inpatient hospitalization not required)


Coordinate circle of care program
Coordinate Circle Of Care Program

  • Include home health care providers in the discharge process

  • Educate home health care work force on SNF rules of participation, clinical capabilities, positive patient outcomes

  • Create an image; the SNF is part of the continuum

  • Common names; Rehab, Short Stay, Post Acute, Transitional Care

  • Section 87 State Health Care Reform Law


Coordinate circle of care program1
Coordinate Circle Of Care Program

  • Coordinate readmission process between home health nurses and SNF

  • Track & trend outcome data and communicate results with stakeholders

  • Expand Circle Events to include direct admits from physician offices and emergency rooms when appropriate

  • Proposed State waiver of qualifying hospital stay


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