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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. Objectives . Upon completion the learner will be able to :

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venues of post hospital care

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

objectives
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
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
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 emotionalresources have been considered.

Medicare Qualifiers

reasonable and necessary” for the treatment of an illness and injury”

and

Requires Skilled Services

and

HOME BOUND

Home with Home Health Care
how much service will medicare pay for
How much service will Medicare pay for?

Services that are:

  • part-time,
  • intermittent,
  • “skilled”
  • Not “24/7 ” home care
skilled services
Skilled Services
  • Registered Nurse
  • Physical therapist
  • Speech therapist

Other services may be added only if one of the 3 above skilledservicesare needed

Example:

-Social work

-Home health aide

-OT

homebound the definition
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
the definition of homebound continued
The Definition ofHomebound-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
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
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
Skilled Nursing Facilities

Moderately complex

Examples:

  • 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 facilities13
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 hospitals
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.
acute rehabilitation how to qualify
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
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 ltach17
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
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 > 4 treatments (e.g. Nebs, IV’s , wound care,)

Bottom line: Ask to see if person qualifies

Attendings: LTACH has list of physicians.

nursing home care
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
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
HOME HEALTH HOSPICEEligibility 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 services22
HOSPICE SERVICES

Interdisciplinary team

  • R.N.
  • Attending Physician
  • Hospice Medical Director (physician)
  • Chaplain
  • Social worker
hospice services continued
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 following24
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%

At time of admission to hospital your elderly patient faces discharge to one of the following:
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

REVIEW of DISPOSITIONS
questions
Questions?

Next;

Review strategies and techniques to ensure timely and appropriate discharge.

what causes delays in getting patients to appropriate and timely 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 unrealistic
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
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

Define discharge by Goals rather that Time
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’s appropriate for discharge disposition
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

Reasons & Remedies for Delays in:Discharge per Social Work
last minute planning remedies
“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
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

Remedies

Realistic expectations (add ADL’s to DC planning )

Introduce reasonable alternatives early

Involve SW & PCP early

Review
end of show
END OF SHOW
  • Questions?
  • Additional References

www.hcfa.gov/medlearn/default.htm

  • ( basic coding, assist with claims)