Settings of Care Board Game Answers

Case #1 Best – Skilled Nursing Facility (SNF) Goal is to get patient eventually to the highest level of independence that is reasonable. Nothing in the history to suggest that she couldn’t live independently (home) again, but since she lives alone, she is not ready to do that yet. Still having pain, unsafe to go home alone already noted, she still needs PT (but is working with PT). SNF will provide time to improve with rehab therapies, patient qualifies for it (at least 3 days in hospital, needs daily therapies, is progressing with therapies), cost is reasonable (Medicare reimbursement, fully for first 20 days, 80% for days ). Other – Home with home health (PT/OT) + a lot of help from friends, family willing to come for awhile to help, or other caregivers

Case #2 Best: Assisted Living Facility /Personal Care Home Patient has two major issues – his cognitive deficits and the new requirement for insulin injections with accuchecks (with or without sliding scale insulin protocol). The cognition problems are not new and unlikely to improve (may be progressive) and the need for insulin is not temporary and dosage will need adjustment. The cognitive deficits are likely to limit his ability to do his insulin therapy correctly (even if daughter draws up insulin into syringes and these stored in refrigerator, patient has to remember to give himself the insulin, interpret accuchecks correctly, to give sliding scale insulin correctly, and to eat regular meals); the cognitive deficits also may limit his ability to give himself insulin injections (a new task). Even if no sliding scale insulin regimen is initiated, he will need daily assistance with his insulin regimen and an accurate measure of accuchecks. He has some financial resources, which means that paying for the additional cost of being in a PCH/ALF may be possible. Most PCHs have staff that can give medications, including insulin, and do some limited monitoring. Other – Home, but would need to find / hire someone to come in daily (on days when daughter couldn’t come) to do accuchecks.

Case #3 Best – Long Term Care Hospital Patient is low income (so can’t afford to pay out of pocket for any medications), is severely functionally compromised currently (ie, can’t live by self), and has no family or others to help her. She needs long term intravenous antibiotics and the antibiotic she needs is extremely costly. Meets criteria for most SNFs, but unlikely to be accepted due to high cost of medication. SNF payments are based on set criteria and are capped for level of care. Medications need to be included in the capped reimbursement. Because of the high cost of the daptomycin, the reimbursement paid to the SNF for this patient’s care would not cover the cost of the medication (and she has no money to pay for the difference). LTCH reimbursement is based on the patient’s diagnoses (DRG), but is higher than that for SNF and should cover the cost of the daptomycin. The patient likely meets criteria for LTCH in that she needs IV antibiotics, some rehabilitation, and monitoring of her infectious process Other – Skilled Nursing Facility - but unlikely to find one that would accept patient because would lose money due to high cost of medications

Case #4 Best – Hospice in NH Hospice – The family, as the patient’s health care decision maker, has decided to no longer hospitalize the patient if he were to get pneumonia or another life threatening illness again. Patient has a severe nonreversible disease which has caused 3 episodes of pneumonia within 3 months. The likelihood of having another such episode within the next 6 months is very high. Therefore, the patient meets the criteria for hospice benefits and care (likely life expectancy of less than 6 months). Hospice benefits are paid out of Medicare (or Medicaid, if no Medicare coverage). Many hospice patients are managed at home, but in this case the family has said they emotionally can’t do that. This patient could be admitted to a long term care facility and receive his hospice benefits there. Hospice benefits, however, do not cover the cost of the long term care facility “room and board”, so that would need to be paid by the patient/family, by Medicaid if patient has that payor, or by long term care insurance if patient had bought that coverage. The cost of inpatient hospice facilities usually are covered under the Medicare benefit, but the average life expectancy for most patients admitted to inpatient hospice facilities is less than 7 days. This patient may not have his next episode of aspiration for several months, so many inpatient hospice facilities would not admit the patient at this point. Other – Inpatient hospice facility

Case #5 Best – Home with family/caregivers and home health for rehab therapies Despite some cognitive deficits, patient is making progress in her rehabilitation. Even at baseline she was not living alone and has multiple family members at home to assist her with ADLs on a 24/7 basis. She needs rehabilitation therapies (PT and OT), but can get these at home through Home Health (patient would qualify as “homebound”). Other – SNF would be an acceptable choice if there is an SNF option that is located within a hospital structure or in a free standing facility. However, most SNFs are physically located within a long term care facility structure, even though the SNF is not for long term care. Therefore, the family and patient’s agreement in regards to “never going to a nursing home” may make the SNF option untenable if they are not able to accept that the SNF is not a “nursing home”. Rehabilitation within an SNF is usually more extensive (5 days a week) than that provided through home health (usually 2-3 days/week).

Case #6 Best - Long term care facility Patient has progressive cognitive dysfunction with complications (paranoia) that, when active, affect her ability to do basic functions (such as eat). Although the complications at the current time can be controlled if she is on psychiatric medications, if left to her own care, her dementia and psychiatric problems would likely lead to her becoming noncompliant with her psychiatric medication (leading to a recurrence of her increased disability). She has no family to assist /assure she takes her medication or help with other ADLs and IADLs. With limited financial resources, she would be most appropriate for admission to a long term care facility (dementia unit) with payment of such care by Medicaid. Other - Home Patient was functioning at home with few resources just prior to her problem with paranoia. If her paranoia remains under control, she may be able to return to home, at least for awhile. This would require, at a minimum, that she be compliant with her psychiatric medication. This might be facilitated by the use of a long acting parenteral antipsychotic and referral for home visits from a psychiatric nurse.

Case #7 Best – Long Term Care Hospital Patient has multiple medical problems that still need ongoing care (PEG tube, diet advancement, extensive physical, occupational, and speech (swallowing) therapies, wound care with wound vac, etc). These problems are multiple and complex enough to require daily evaluation by a physician and would qualify him for LTCH admission. Depending on how he progresses, he may need discharge from LTCH to SNF for further rehabilitation prior to going home. Other - SNF Patient has a number of daily skilled care needs, but if everything were stable and/or improving, a high level care SNF could manage his rehab therapies (PT, OT, SLP), his PEG tube feedings, and his wound vac.

Case #8 Best: Home with Home Health Patient has been living independently up until her new onset of congestive heart failure. Her long standing low vision should not interfere with the at home management of her congestive heart failure if she gets an appropriate scale (large numbers or voiced). Home health nursing monitoring of her weight, lungs, and vital signs can be done initially, and they can also provide CHF management education. Unless the patient is significantly physically deconditioned from the hospitalization for her CHF, home with home health is the best option. Other SNF- Since the patient lives alone, if she has physical de- conditioning as a result of her CHF or the hospitalization, then SNF would be an appropriate option.

Case #9 Best -Assisted Living Facility /Personal Care Home Patient lives alone, has cognitive problems, and no family in the area to assist him. He has demonstrated repeatedly his inability to comply with diet and his medication regimen for congestive heart failure. He has no major physical function disabilities and some financial resources, so the medication administration assistance and dietary controls offered by a ALF would be beneficial. He also might benefit from the available social interactions and activities in an ALF. Other – Home with hired caregivers If there is a personal preference to remain in the senior independent living apartment, the patient (or his family) could hire the caregiver assistance needed to see that his medications are administered correctly, that he weighs himself daily, and that his access to inappropriate diet is somewhat limited.