WHAT DO WE DO WITH THIS PATIENT? DISCHARGE PLANS Susan T. Bray-Hall, MD

1. WHAT DO WE DO WITH THIS PATIENT?DISCHARGE PLANSSusan T. Bray-Hall, MD AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults.

2. ONE YEAR OF CHRONIC ILLNESS 18days in hospital,35 days in NH …… 312 days at home Hospital: MI, CHF Hospital: CHF Hospital: A-fib, Stroke 4 days 8 days 6 days Nursing home stay Home health episodes 45 days 62 days 28 days 35 days Courtesy Peter Boling, MD

3. Background: Medicare • Part A • Hospital, hospice, home care, skilled nursing facility, equipment • Part B • Outpatient care, MD services (80% coverage) • Part D • Pharmacy benefit

4. Background: Medicaid • State-specific • Income limit $600$1800/month • Asset limit $2000 • Covers co-pays, home care, equipment, transportation

5. Discharge Options • Acute inpatient rehabilitation • Skilled nursing facility (SNF) / Transitional care unit (TCU) • Home with skilled home health care • Nursing home • Hospice

6. ACUTE INPATIENT REHABILITATION • Patient can tolerate 3 hours of rehabilitation daily • Post-stroke, postjoint replacement, post-amputation, brain or spinal cord injury • NOT general decline from medical illness

7. ACUTE INPATIENT REHABILITATION:Who Pays? • Medicare A • Days 120: 100% • Days 21100: 80% • Remainder from private pay, private insurance, Medicaid • Approximate cost $600/day

8. SNF/TCU • Patient needs post-hospital rehabilitation • Patient requires 3-night hospital stay (within 30 days) • Nursing, physical therapy, occupational therapy, speech therapy • Patient is required to make continued progress

9. SNF/TCU: Who Pays? • Medicare A • Days 120: 100% • Days 21100: 80% • Co-pay: private pay, private insurance, Medicaid • Approximate cost $350$600/day

10. HOME WITHSKILLED HOME HEALTH CARE • Primary caregivers: • Nursing (wound, med adjustment, disease monitoring) • Physical therapy • Speech therapy • Secondary caregivers: OT, MSW, RD, CNA

11. SKILLED HOME CARE: Who Pays? • Medicare A • Pays for non-physician services • No limit on length of care but paid on DRG • Patient must be homebound • Medicare B pays 80% of physician visits

12. UNSKILLED HOME CARE:Who Pays? • Private pay • Medicaid: up to 40 hours/week of Home and Community Based Services (HCBS)

13. NURSING HOME • Custodial care only • Patient would have no benefit from skilled rehabilitation

14. Nursing Home: WHO PAYS? • Medicaid or private pay • $50,000$80,000/year • $150/day (Medicaid rate)

15. HOSPICE • “Would I be surprised if this patient died within the next 6 months?” • Patient needs onehospice diagnosis

16. HOSPICE: Who Pays? • Medicare A • Pays for hospice team and medications • Does not pay for room and board

17. Successful Transitions (1 of 3) • Discharge planning • Patient activation • Medication reconciliation • Red flags • Follow-up • Discharge summary • Does not need chronology • Needs outcomes! • Timeliness!

18. Successful Transitions (2 of3) • Medication reconciliation • Focus on medication changes • Pink sheet/Transfer orders • Full medication list • Labs needed • Follow-up plans • Services requested; wound care orders, etc.

19. Successful Transitions (3 of3) • Think of transitions as a medical procedure • Improve patient safety • Improve patient care • Improve patient satisfaction

20. It is AS importantwhere and how you discharge the patient as the procedures and treatments you didin the hospital

21. Thank you for your time! Visit us at: www.americangeriatrics.org Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics linkedin.com/company/american-geriatrics-society