Home Health Partnering for Resident Independence in Assisted Living Environment

1. Home Health Partnering for Resident Independence in Assisted Living Environment Brynne Malone Regional Director of Sales IntrepidUSA Healthcare Services

2. Educate as to life enhancing benefit of home health. • Provide understanding of CMS guidelines, restrictions and expectations of providing home health to Medicare beneficiaries. • How to recognize early residents who might be at risk of losing their independence. Objectives

3. 10-15% of the senior living population likely have needs for therapy or nursing.

4. Building staff are often not medically trained. They may not notice subtle changes indicative of potential medical issues.

5. Only 30% of needs are identified by building staff. • Other issues are missed until an incident like a fall, a hospitalization or a significant decline occurs. Result

6. Partnering with a home health agency provides opportunity for on-sight therapists, identifying changes in the residents behavior and function to prevent the other 70% from experiencing an incident. Why Home Health?

7. The average length of stay in an ALF is 27 months. Over the course of those 2 years the residents health and function gradually decline. Statistics

8. Educate staff regarding what issues can be addressed before an incident occurs • Raise awareness by discussing current caseload • Screen and uncover needs by asking specific questions Involving Home Health

9. Actively listen to answers • Verbalize where we can make a difference • Engage staff to follow steps to obtain necessary care Involving Home Health

10. A ALF department head meeting or care conference held at least weekly. A therapist from home health care will attend the meeting and participate in the resident status portion of the meeting only. Identification process

11. This will aid in the identification of residents with needs that can be met by the home health agency. Identification process

12. Clinician will provide report at each meeting: • Current caseload • Progress • Lack of progress • Contact with family members • Interactions with staff regarding residents Identification process

13. Are there any upcoming tours? • Most people consider moving to an ALF because of a decline in function • Likely the reason for the decline can benefit from medical interventions • Knowing they can receive care on-site makes moving in more attractive • If they don’t move in, we can still deliver care in their existing or new home Identification process

14. Are there any upcoming move-ins and have needs for services been assessed? Residents may move in without meeting our team as part of the tour. The moving process is stressful. Medical conditions can be exacerbated by the stress of the move. It is important to get the residents the care they need. Identification process

15. Have any current residents been sent to the hospital, ER or SNF? If yes, is that resident going to be receiving a visit and has that resident given permission for staff to visit? Identification process

16. This helps educate the discharge planners as to what services can be provided in the ALF and reduce the number of residents: • Who are sent to a rehabilitation unit • Who are referred to other providers of home care and outpatient services Identification process

17. Are any residents returning from the hospital, ER or SNF? Have their needs been assessed by ALF Staff? Knowing the return date aids in completing necessary documentation to provide care ahead of time Identification process

18. Have there been any falls since the last meeting? Have those residents been assessed for needs by ALF staff? • A fall list is an important reference. • It is a good idea to screen all residents who fall. Identification process

19. Are there any noticeable declines or changes in resident function, participation or behavior? Change is often an indicator of a medical issue and should trigger a need for a screen. Identification process

20. Every department head may be noticing changes but may not be aware of the medical implications. Identification process

21. Examples: Changes in dress could be a result of musculoskeletal or cognitive issues Decreased participation could be a result of shortness of breath which can be secondary to many chronic diseases. Identification process

22. Are there any scheduled assessments of residents? Buildings assess residents to ascertain appropriateness to live in the building. They will be noting decline in function and increased utilization of assistant staff. These changes should trigger a screen. Identification process

23. Are any residents ordering dining trays to be delivered to their rooms? Have their needs been assessed by ALF staff? Identification process

24. Residents may begin isolating themselves from their peers which should trigger a screen. • Dexterity issues result in difficulty using silverware, causing messiness. • Drooling or coughing when chewing or swallowing. • Difficulty with conversations • Weight loss or weight gain Identification process

25. Are any residents being discharged from the service of another Home Health Agency or outpatient therapy provider? It is possible that other providers are not as complete in their understanding of appropriate goals for the residents and have discharged them too soon. Identification process

26. Other recommendations? Conversation prompts recollection of issues that the department heads may have seen or overheard. It is always important to ASK if there is anything that should be mentioned Identification process

27. Partnering with a home health agency enables appropriate interventions to be delivered so that the residents are able to age in place in optimal health. Why Home Health?