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FORGING THE PATH FOR MEDICAL RESPITE CARE IN HEALTH SYSTEM REFORM August 16, 2014 Alice Moughamian, RN, CNS, San Francisco Medical Respite Program Sabrina Edgington, MSSW, National Health Care for the Homeless Council WHY STANDARDS? • • • • Improve consistency Improve quality, health outcomes, and reduce costs Improve opportunities for research Improve opportunities for sustainable federal funding A 2014 study conducted by Duke University found an emergence of “patchwork [medical] respite” processes in the absence of formal medical respite programming. Source: Biederman, D.J., Gamble, J., Manson, M., Taylor, D. (2014). Assessing the need for a medical respite: perceptions of service providers and homeless persons. Journal of Community Health Nursing, 31(3),145-56. PROCESS TO DATE • Under Leadership of Medical Respite Providers Network • Medical Respite Standards Development Task Force → Representatives of Nursing, Social Work, Medical, Policy, Legal and Consumer Viewpoints • Conducted monthly meetings → Began Fall 2011 • Focus on the minimum standards • Alignment with other standards • Goal to accommodate a diverse range of providers 4 STANDARD 1: ACCOMMODATIONS MEDICAL RESPITE PROGRAMS PROVIDE SAFE AND QUALITY ACCOMMODATIONS • • 24 hour bed Hygienic → → → → • • Shower facilities Laundering facilities Clean linens Janitorial services Accessible and minimal fall risk Secured storage STANDARD 1: ACCOMMODATIONS • • Food (3 meals/day) 24 hour staff presence → Trained in first aid and basic life support → 24-hour on call medical support at non-congregate facilities • Safety plans → Policies and procedures for responding to life-threatening emergencies (i.e., medical emergencies) → Patient understanding of fire and evacuation plans → Code of conduct → Policy for handling alcohol and illegal or non-medical prescription drugs → Policy for weapons and staff response to violence STANDARD 2: ENVIRONMENTAL SERVICES MEDICAL RESPITE PROGRAM PROVIDES QUALITY ENVIRONMENTAL SERVICES • • • • Safe handling of biomedical and pharmaceutical waste and other biohazardous materials as needed Communicable disease management Medication storage Pest Control 7 CONSIDERATIONS FOR COMMUNICABLE DISEASE MANAGEMENT OTHER CONSIDERATIONS FOR COMMUNICABLE DISEASE MANAGEMENT • • • TB C. diff Hep A → Fecal – oral route → Implications in food service (i.e., Standard 1) • Impetigo → Standard 1 implications • Shingles MEDICATION STORAGE • Licensing → Administering vs. Dispensing → Meds need to be stored according to manufacturer requirements • Special considerations → Insulin → Controlled medications → Oral chemo agents • Special precautions → Outpatient chemo STANDARD 3: CARE TRANSITIONS TO MEDICAL RESPITE MEDICAL RESPITE PROGRAM MANAGES TIMELY AND SAFE CARE TRANSITIONS TO MEDICAL RESPITE FROM ACUTE CARE, SPECIALTY CARE, AND/OR COMMUNITY SETTINGS CARE TRANSITIONS: The movement of patients between health care locations, providers, or different levels of care within the same location as their conditions and care needs change. This may include the transition from the hospital to a primary care provider, home, or nursing facility. National Transitions of Care Coalition. (2008). Transitions of care measures. Retrieved from www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf STANDARD 3: CARE TRANSITIONS TO MEDICAL RESPITE Improving Care Transitions for People Experiencing Homelessness http://www.nhchc.org/wp-content/uploads/2012/12/Policy_Brief_Care_Transitions.pdf STANDARD 3: CARE TRANSITIONS TO MEDICAL RESPITE Preadmission → Working with hospitals to promote medical respite as a discharge option → Trainings to promote appropriate referrals → Timely admission decisions by qualified medical personnel → Admission decisions based on ability to keep patients safe and provide the care, treatment, and services needed by the patient → Communication with referring agencies when beds are not available or a referral is denied STANDARD 3: CARE TRANSITIONS TO MEDICAL RESPITE Admission → Designated point of contact for referring entities → Transportation responsibilities from referring entity to medical respite is outlined in written agreements → Protocols for transferring patient information → Medication reconciliation → Reinforcement of discharge instructions → Patient has and knows his/her accountable provider(s) at all points of care transition STANDARD 4: CLINICAL CARE MEDICAL RESPITE PROGRAM ADMINISTERS HIGH QUALITY POST-ACUTE CLINICAL CARE • • • • • Clinical care provided at the medical respite program Ensures an adequate level of care Requires qualified medical personnel Patient focused Interdisciplinary 15 QUALITY POST-ACUTE CARE • • Medical records maintained according to local, state, and federal guidelines Patients have encounters with clinical staff based on medical need → RN’s on-site, consult provider as needed → Provider on-site for referral consultation, admissions, urgent issues, pain management, medication changes • • q24 hour wellness checks Providers follow clinical practice guidelines QUALITY POST-ACUTE CARE • Interdisciplinary team → Care and treatment discussed on regular basis with all members → All information is shared with team and patient → Meets regularly to assess plan and progress towards goals • Individualized Respite care plan → Patient care is delivered in an interdisciplinary and patient centered manner. → Developed in a collaborative manner → Care plans are assessed, reassessed and altered accordingly STANDARD 5: CARE COORDINATION/SUPPORT SERVICES MEDICAL RESPITE PROGRAM ASSISTS IN HEALTH CARE COORDINATION, AND PROVIDES WRAP AROUND SUPPORT SERVICES. • • • • Care coordination within the medical respite program and during the medical respite stay Medical care coordination Case Management/Social Services Coordinate or provide transportation to medical and social service appointments 19 CARE NAVIGATION • • • • • Connection to Community PCP Connection to Community Specialty Care Pharmacy reconciliation Transportation to and from appointments Connection to community case management OTHER EXAMPLES • • • • • • • Respite as an opportunity Nutrition, rest, recovery Housing process can begin Benefits acquisition Mental Health referrals Substance use referrals Medication adherence and teaching CASE STUDY: MR. H • • • 54 y/o male with uncontrolled diabetes, s/p amputation of R 5th toe for osteo and gangrene Comes to respite for post op recuperation and follow up. Exchanging security services for room/board. Now that he is unable to work, has lost housing. MR. H: MEDICAL CARE PLAN Medical Care Coordination • • • • Wound care Podiatry and Diabetes follow up Establish PCP Blood sugar, diet, glucometer teaching MR. H: SOCIAL SERVICE PLAN Social Service Care Coordination • • • Erroneously put on SSDI in 2002. Has since been unable to get ID, job, benefits Ethics for discharge prior to SSDI being resolved Discharge Planner (MSW) worked to get birth cert, fingerprints, hospital records, involved local, state and federal agencies. Pelosi’s aide got meeting with SSA MR. H: RESULT • • • • Although engaged in the medical care plan, required follow up surgeries, additional amputation While taking care of medical needs, could use time to handle social service needs Ended up as our second longest length of stay ever (234 days) Just moved to permanent supportive housing on Tuesday STANDARD 6: CARE TRANSITIONS FROM MEDICAL RESPITE MEDICAL RESPITE PROGRAM FACILITATES SAFE AND APPROPRIATE CARE TRANSITIONS FROM MEDICAL RESPITE TO THE COMMUNITY. • Discharge planning → Begins early → Discharge policy & procedure, including who makes discharge decisions → Pt receives at least 24 hours notice prior to discharge from medical respite (exceptions for administrative discharge) • • Discharge summary to the patient and community providers assuming patient care Patient provided with options for placement after discharge STANDARD 7: MEDICAL RESPITE CARE IS DRIVEN BY QUALITY IMPROVEMENT • • Requires competent staff Systematic and continuous actions that lead to measurable improvement in Respite outcomes 28 STAFFING REQUIREMENTS • Core competencies for staff → Includes volunteers • • • • • Job descriptions and annual performance appraisals Medical director required Appropriate training, certification and licensing is maintained Staffing based on program’s ability to provide clinical care and clinical complexity and acuity. Incident reporting DATA MEASUREMENT • Established and secure data collection process → Program specific performance priorities for data collected and frequency • • Plan to identify and respond to trends, outcomes, patient experience and performance measures. Ability to conduct self audits LCR MED REC # DPH MEDICAL RESPITE Episode Form CITY AND COUNTY OF SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH DPH MEDICAL RESPITE Episode Form, PAGE 2 CAUTION: Federal and State laws protecting confidential patient information apply to patient information contained in this completed form. MEDICAL RESPITE CLIENT INFORMATION FIRST NAME SSN DOB MEDICAL RESPITE LINKAGES REFERRED BY WHICH HOSPITAL (choose one) YEAR SFGH St. Francis Kaiser CPMC Davies VA Hosp CPMC Pacific St. Mary’s CPMC California St. Luke’s Other Hosp (specify): PRIMARY LANGUAGE GENDER ORIENTATION/PREFERENCE Caucasian African American Latino/a Filipino/a English Spanish Other: Male Female MTF Transgender FTM Transgender Other Declined to Answer Heterosexual Gay Lesbian Bisexual Unsure Other Declined to Answer CURRENT LIVING SITUATION Other: Choose one: Select situation that applied prior to client’s hospitalization. Asian American Indian / Alaskan Native Native Hawaiian or Other Pacific Islander Homeless: Homeless Transitional: Permanently Housed: (with tenancy rights): SRO Non-Supported SRO Supported Board and Care Apartment House Shelter, no CM Shelter, with CM Outdoors Encampment Abandoned Bldg Vehicle Other Diagnostics: Pharmacy: _______________________________________ N/A Already Active Reconnect New Connect Offered/Refused ICM Team: _______________________________________ N/A Community Nursing Care: MONTH: ___________ YEAR: ___________ SA Tx: Already Active Reconnect New Connect Offered/Refused ___________________________ N/A Already Active Reconnect New Connect Offered/Refused Already Active Reconnect New Connect Offered/Refused __________________________________________ N/A Already Active Reconnect New Connect Offered/Refused Specialist: _____________________________________________ N/A Already Active Reconnect New Connect Offered/Refused Specialist: _____________________________________________ N/A Already Active Reconnect New Connect Offered/Refused Other: __________________________________________ N/A Already Active Reconnect New Connect Offered/Refused (choose only ONE option from MEDICAL HISTORY below and write here) Housing: _______________________________________________ Already Active REFERRING PRIMARY PURPOSE(S) FOR ADMISSION (choose all that apply): ID: ARV Initiation Wound Care PO Antibiotics IV Antibiotics Med Mgmnt Reconditioning/Rehab CM Anticoagulation Med Teaching Chemo/XRT Awaiting Medical Procedure Assisting with Follow-up Other (specify): Unable / Refused to Answer Denies History Ambulatory Disability Anemia Assault Asthma Autoimmune Disease CAD Cancer Cardiac Arrhythmia CHF Chronic Pain Cirrhosis Cognitive Disorder NOS COPD Dental Condition Derm Condition Diabetes Endocrine GI Disease Other (specify): IDENTIFIED DURING STAY: REFERRAL MH HISTORY GYN Disease Hepatitis C HIV/AIDS Hypertension Neuro disease Open wounds, skin and soft tissue infection Ortho Condition Osteomyelitis Pneumonia Post-Op Care Renal Disease Seizure disorder TBI Thromboembolic Disease Urologic Condition UTI Vision Disability Unable / Refused to Answer Denies History None Adjustment Disorders Substance Related Diagnoses Anxiety Disorders Delirium, Dementia, and Amnesic and Other Cognitive Disorders Disassociative Disorders Factitious Disorders Impulse Control Disorders Not Elsewhere Classified Mood Disorders Personality Disorders Schizophrenia and Other Psychotic Disorders Sexual and Gender Identity Disorder Sleep Disorders Somatoform Disorders Other Conditions (specify): IDENTIFIED DURING STAY: Unable / Refused to Answer Denies History None Alcohol Barbiturates and other sedatives / hypnotics Benzodiazepines and other tranquilizers Cocaine / Crack Cocaine Ecstasy & other club drugs Hallucinogens / PCP Heroin Inhalants Marijuana / Hashish Methamphetamine and other amphetamines Nicotine Other Opiate * Over-the-counter * Unknown drug(s) * * Specify: Already Active Applied, Award Date:_______________________ Offered/Refused Medical Coverage Benefit: Medi-Cal / Medicare / VA: DID STAY RESULT IN CHANGE OF LIVING SITUATION? NO If YES check new situation: Already Active Applied, Award Date: __________________ Offered/Refused Homeless: Homeless Transitional: Permanently Housed: (with tenancy rights): SRO Non-Supported SRO Supported Board and Care Apartment House Shelter, no CM Shelter, with CM Outdoors Encampment Abandoned Bldg Vehicle Other SRO Temporary Jail/Prison LTC or Residential Treatment Temp situation w family/friends Foster Care SRO living with child(ren) COMMENT: DISCHARGE DISPOSITION MONTH DAY MEDICAL TREATMENT PLAN COMPLETED BEFORE DISCHARGE? YEAR YES NO, COMMENT: Discharged to: (review options 1 through 15, select only one) 1. 2. 3. 4. 5. 6. IDENTIFIED DURING STAY: Applied Offered/Refused CA ID / SS# Card / Other : _____________________________ Already Active Applied Offered/Refused Income Benefit: CAAP / SSI / SSDI / VA / Other: REFERRAL SA HISTORY Reconnect New Connect Offered/Refused ___________________________________________ N/A Already Active Reconnect New Connect Offered/Refused MH Tx: __________________________________________ N/A LAST TIME CLIENT WAS PERMANENTLY HOUSED: REFERRING PRIMARY DIAGNOSIS AT ADMISSION: REFERRAL MEDICAL HISTORY SRO Temporary Jail/Prison LTC or Residential Treatment Temp situation w family/friends Foster Care SRO living with child(ren) PC Provider: __________________________________________________ Already Active DC LIVING SITUATION ADMIT PURPOSE ETHNICITY (choose all that apply) CLIENT INFO UCSF TIME M.I. ADMIT LIVING SITUATION ADMIT DATE ALIASES DAY FIRST NAME DATE: BRIEF DESCRIPTION OF ADVERSE EVENT LAST NAME MONTH LAST NAME ADVERSE EVENT 7. 8. * Psychiatric Emergency Program/Facility: * Medical Emergency Department: PES Westside Crisis Dore Urgent Care Clinic 5150? Yes No St. Luke’s SFGH St. Francis CPMC Davies CPMC Pacific CPMC California UCSF Kaiser VA Hosp St. Mary’s Other Hospital: ________________________________________ 12. 13. 14. 15. Medical Detox Program 9. AWOL Social Detox Program 10. Residential Treatment Program: ____________________ 11. * Escorted out due to violent behavior or threat of * Discharged due to inappropriate behavior * AMA * Discharged to Police Custody * Death Hospice: ______________________________________ Long Term Care: ________________________________ Completed program and discharged to self-care Address/hotel/room#, if known: _________________________________________________ 415-255-3706 – Form Revised 051309 Other as follows: ______________________________ (* Requires Adverse Event section to be completed) ENTERED INTO CCMS: DATE: _____________________BY: _______________________ NEXT STEPS • Anticipated public comment period: 9/1/14-9/30/14 • Revisions based on public comment/Task Force discussion • Testing at volunteer sites • Revisions based on testing • Final standards issued NEXT STEPS • Used for training and technical assistance • Opportunities for accreditation/certification • Opportunities for research related to health outcomes/quality of care/costs • Engage in discussions at federal level to promote sustainable funding Q&A Alice Moughamian, RN, CNS, Nurse Manager San Francisco Medical Respite Program [email protected] Sabrina Edgington, MSSW, Director of Special Projects National Health Care for the Homeless Council [email protected]