Download Community Resources

Community Resources
Linda Cragin, Director
MassAHEC Network
4-30-2012
Today’s Objectives
• Understand the importance of care
transitions
• Understand the range of community
services available.
• Understand how to access community
services.
• Understand the important role of
informal/family caregivers.
Care Transitions:
• Hospitalizations account for approximately 33 percent
of total Medicare expenditures ($524 billion in 2010)
and represent the largest program outlay.
• The Medicare Payment Advisory Commission
estimated Medicare costs of approximately $15 billion
due to readmissions,
• $12 billion of which is for cases considered
preventable.
www.cfmc.org
Within 30 days of
discharge,
19.6 % of Medicare
beneficiaries are rehospitalized.
Jencks SF, Williams MV, Coleman EA:
Rehospitalizations among patients in the Medicare
Fee-for-service Program. NEJM 2009 Apr 2;
360(14):1418-28
Care Transitions:
Hospitals have traditionally served as the focal
point of efforts to reduce readmissions by focusing
on those components that they are directly
responsible, including the quality of care during the
hospitalization and the discharge planning process.
… multiple factors along the care continuum that
impact readmissions, and identifying the key
drivers of readmissions for a hospital and its
downstream providers is the first step towards
implementing the appropriate interventions
necessary for reducing readmissions.
www.cfmc.org
Care Transitions: BOOST
Better Outcomes for Older Adults through
Safer Transitions:
•
•
•
•
•
•
•
•
Patient and Caregiver Involvement
Concerns following discharge/Reengineering systems
Medication reconciliation
Adverse events after discharge
Handoff communication and Discharge
Readmission
Preparing Patients for Discharge
Teamwork and Interdisciplinary Rounds
STAAR:
STAAR hospital- community teams focus on
the implementation of four key process-level
improvements that require extensive
collaboration between the hospitals and
their community partners to effectively codesign better processes:
STAAR:
1. Perform an Enhanced Assessment of Post-Hospital Needs
A. Involve family caregivers and community providers as full partners in
completing a needs assessment of patients’ home-going needs.
B. Reconcile medications upon admission.
C. Create a customized discharge plan based on the assessment.
2. Provide Effective Teaching and Facilitate Enhanced Learning
A. Customize the patient education materials and processes for patients and
caregivers.
B. Identify all learners on admission.
C. Use Teach Back regularly throughout the hospital stay to assess the
patient’s and family caregivers’ understanding of discharge instructions and
ability to perform self-care.
STAAR:
3. Provide Real-time Handover Communications
A. Reconcile medications at discharge.
B. Provide customized, real-time critical information to next provider(s).
C. Give patients and family members a patient-friendly discharge plan.
D. For high-risk patients, a clinician calls the individual listed as the patient’s
emergency contact to discuss the patient’s status and plan of care.
4. Ensure Timely Post-Hospital Care Follow-Up
A. Identify each patient’s risk for readmission.
B. Prior to discharge, schedule timely follow-up care and initiate clinical
and social services based upon the risk assessment.
So where do patients go?
Who needs to be involved in transitions planning?
Rehabilitation Hospitals
Skilled Nursing Facilities/Long Term Care
Home Health Services
Outpatient Rehab
Hospice
Other community resources
Family
Rehabilitation Hospitals:
• specialty hospitals (or parts of acute care hospitals)
that offer intensive inpatient rehabilitation therapy
• require a high level of specialized care (3+ hours of
therapy a day) from a team (MD, RN, PT/OT) that
cannot be provided in another setting
• stroke, spinal cord, brain injury…with improvement
potential!
• less likely: hip fracture, knee replacement
unless there are complications
• Coverage: Medicare Part A
Skilled/Extended Care Nursing
Facilities:
• Medicare covers skilled care for 1-20-100 days
• Medicaid, long term care insurance and private
payment for long term/chronic/extended care.
• Team based approach to care: Nursing, PT, OT, ST,
SW, Activities/Recreational Therapist, pharmacist
consultant, medical director
• Other resources: clergy, volunteers, etc.
• Scheduled interprofessional care planning meetings
with patient/family involvement.
Skilled/Extended Care Nursing
Facilities:
• Medicare: Patient needs skilled nursing care
seven days a week or skilled therapy services at
least five days a week.
• Patient was formally admitted as an inpatient to a
hospital for at least three consecutive days in the
30 days prior to admission in a Medicare-certified
skilled nursing facility (not ER observation!); and
• Medicare Part A covered the hospital stay
• Critical opportunity for better transitions planning
Home Health Services:
Skilled, Intermittent, Homebound
• No more than 8 hours per day and 28 hours per week.
• Skilled nursing: can only be performed by a licensed nurse.
Injections (and teaching patients to self-inject), tube feedings, catheter
changes, observation/assessment, care plan management/evaluation, wound
care, etc.
• Home health aide: if patient requires skilled services.
Includes help with bathing, toileting, dressing, etc.
• Skilled therapy: can only be performed by a licensed therapist:
PT: includes gait training and supervision of and training for exercises to
regain movement and strength
ST: include exercises to regain and strengthen speech and language skills.
OT: to regain the ability to do usual daily activities: eating and dressing.
• Medical social services: social and emotional concerns
• Coverage: Medicare Part A, no deductible/co-insurance
• Critical for connection for transitions planning
Home Health cont…
• Medical supplies: certain supplies provided by the
Medicare-certified home health agency, such as
wound dressings and catheters.
• Durable medical equipment (DME): 80% of
Medicare-approved amount for equipment such as a
wheelchair or walker.
• Nothing covered in the bathroom!!!
• Can sometimes get loaner equipment.
• Elders are creative and share!
Outpatient PT, OT, ST
• Medically necessary with a plan of treatment
periodically reviewed by MD
• Medicare will only cover therapy if improvement or
to prevent deterioration
• Limits! 2012: Medicare will cover up to $1,880 for
physical and speech therapy combined, and another
$1,880 for occupational therapy.
• If patient approaches the limit and needs more, MD
can tell Medicare that it is medically necessary
• Coverage: Medicare Part B
Hospice:
• Hospice medical director (and patient’s doctor) certify
that a terminal illness (life expectancy is <6 months)
• Patient signed statement electing to have Medicare
pay for palliative care such as pain management,
rather than care to try to cure your condition
• Terminal condition is documented in medical record
• Receive care from a Medicare-certified hospice
• Patient does not need to be homebound. The benefit
is a comprehensive set of services delivered by a
team of providers.
Hospice cont…
• Comprehensive services: RN, PT/OT/ST, pastoral
care, social work, volunteers, respite, etc.
• Benefit includes two 90-day benefit periods followed
by an unlimited number of 60-day benefit periods.
Starting April, 1, 2011, patient must have a face-to-face
meeting with a hospice MD or NP if reaches 3rd benefit
period. Continued meetings on a prescribed schedule.
• Coverage: “original Medicare” Part A
Medicare Advantage Plans
• Health Maintenance Organizations (HMO)
• Preferred Provider Organizations (PPO)
• Private Fee-For-Service (PFFS) plans.
• Special Needs Plans (SNP)
• Provider Sponsored Organizations (PSO)
• Medicare Medical Savings Accounts (MSAs)
In Massachusetts:
Senior Care Options (SCOs)
Program for All Inclusive Care for the Elderly (PACE)
Evercare
Some blend Medicare and Medicaid coverage…
Community Resources
• 1-800-age-info www.800ageinfo.org
• Aging Services Access Points (in MA)
- Family Caregiver program
- Assessment for in-home services
- A homemaker for cleaning and meal prep
- A home health aide for personal hygiene
• Social Day Care or Adult Day Health
• Transportation
Community Resources:
• Assisted Living and Supportive Housing
• Councils on Aging/Senior Centers- a
city/town run center – social, recreational,
information and referral, meals, etc.
• Y M/W CA’s – wellness/exercise programs
• RSVP- Retired Senior Volunteer Program
• SCORE – Senior Corps of Retired Executives
• Money Management programs, AARP tax
assistance, etc.
Family Caregivers
• Family caregivers are the foundation of long-term
care nationwide.
• More than 65 million people, 29% of the U.S.
population, provide care for a chronically ill, disabled
or aged family member or friend during any given
year and spend an average of 20 hours per week.
• The value of these “free” services is estimated to be
$375 billion a year; almost twice as much as is
actually spent on homecare and nursing home
services combined ($158 billion).
National Alliance for Caregiving 2009 various studies
Home Care, Nursing Home Care,
Family Caregiving and
National Health Expenditures, U.S. 2004
Billions of Dollars
$1,878
$306
$43
$115
Home Care Nursing Home Economic Total National
Care
Value of
Health
Informal
Expenditures
Caregiving
(midrange)
Expenditure data from Office of the Actuary, CMS, Smith C, et al., Health Affairs. 2006;25.
The typical family
caregiver:
• A 49-year-old woman caring for her widowed 69year-old mother who does not live with her.
• She is married and employed.
• Approximately 66% of family caregivers are women.
• More than 37% have children or grandchildren under
18 years old living with them.
National Alliance for Caregiving 2009
Family Caregiving by State, 2004
Summary:
There are many community resources…
There are skilled, trained, professional staff
caring across the spectrum of services…
Communication and coordination is critical…
Patient and family involvement is a must…
And… remember:
1-800-age-info www.800ageinfo.org