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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