Presenter: Thom Bishop-Miller, LPN Complex Care Transitions for the Seriously Ill Patient; Transition from Hospital to Home Health Presenter: Thom Bishop-Miller, LPN

Barriers Discharge planning When is it initiated Patient/Family involvement Destination; will patient go home alone, or with family Identifying services needed or already in place Primary Care Physician Is the Patient currently on a Home Health Service

Barriers Insurance specifications Home Health face to face Type of policy may dictate; number of visits, disciplines covered, or out of pocket costs Homebound requirements Home Health face to face Documentation must show reason for each skilled discipline ordered Homebound status must list reason patient cannot safely leave home alone

Interventions Initiate discharge process to Home Health as soon as indicated Identify if patient will go home alone or with family Identify if patient/family able/willing to perform care Identify all disciplines needed

Interventions Verify services already in place/needed Primary Care Physician Home Health/Hospice Advantage Program Durable Medical Equipment (DME)

Interventions Insurance specifications Home Health face to face Early referral will allow Home Health to verify benefits/homebound Home Health face to face Documentation must indicate reason for each skilled discipline ordered Documentation must indicate specific homebound status (why patient cannot safely leave home alone)

Complex Care Transitions for the Seriously Ill Patient; Transition from Hospital to a Skilled Nursing Facility (SNF) Presenter: Joan Williams

Medicare Changes BPCI (Bundled Payment for Care Improvement) Bundled Reimbursement Identifying the patients which fall into the bundled payment category Shorter Length of Stay (LOS) More Community Based Care

Barriers Misinformation regarding expectations of a Skilled Nursing Facility Lack of financial resources Medicare Vs Insurance (HMO, PPO, Worker’s Comp, etc.) Medicaid Vs Private Pay

Barriers Psychosocial barriers which inhibit discharge from SNF Poor family support Unsuitable home environment Misinformation regarding available resources after discharge from SNF

Interventions Discharge planning upon admission to SNF Identify level of care needed for appropriate discharge placement from the hospital Partnering with other healthcare providers to prevent readmission to the acute setting Outpatient Therapy Home Health Hospice Private Duty, etc.

Complex Care Transitions for the Seriously Ill Patient; Transition from Hospital to Hospice Presenter: Stacey Kelly

Barriers Lack of patient and family education on meaning of hospice Receiving services at appropriate time Financial benefit of hospice services Physician uncomfortable with the hospice conversation Long term relationship with patient Healing focus now becomes palliative

Barriers Patient’s financial burden Patient and family emotions Skilled Nursing vs. Hospice in facility setting Need for partnerships to provide options for patient’s care following discharge Patient and family emotions Need time to process emotional aspect of diagnosis Unrealistic expectations of treatment

Interventions Educate the patient and family on hospice expectation prior to hospital discharge Supplemental medical team What is covered, what is not? Home environment Contact the PCP or attending physician prior to hospital DC

Interventions Dot the I’s and cross the T’s Hospice Order DC date and time DME and Medication plan prior to DC Involve hospice social worker and chaplain early for patient/family emotional support Smooth transition for: Patient and Family Hospital

Medicare Changes in Hospice Presenter: Keisha Jackson I have been in the health care industry for over 23yrs and most everyone I have met who goes into health care really means well. I am sure everyone in this room would agree that they got into health care to help people not to fill out another form. The American Health care system has its fair share of dysfunction to match its brilliance. Hospitals are places for acute trauma or illness they are no place to live or die. That is not what they are designed for. Health care was designed with diseases not people at its center. Which is to say it was designed badly. Nowhere are the effects of bad design more heart breaking or the opportunity for good design more compelling than at the end of life, where things are so distilled and complicated. There are no do overs. For most people the scariest thing about death is not being dead its dying or suffering. It’s a key distinction. How we die is indeed something we can effect. We need to set our sights on wellbeing. So that life, health and health care can become about making life more wonderful rather than just less horrible.

Medicare Changes in Hospice Continuous Care Medications Payments Face to Face requirements HIS Reporting visit units (Nurse, Social Worker, Chaplain) SIA (visit by RN or Social Worker at last week of death

New HQRP Measure Hospice visits when death is imminent Assessing hospice staff visits to patients and caregivers in the last week of life

Collection impacts payments in FY 2019 New HQRP measure  Collection of the two new measures would impact payments in FY2019 and hospices will begin collecting the data for these measures for all patients admitted on or after April 1, 2017 via four new HIS items.  The Hospice visits when death is imminent measure The measure addresses whether a hospice patient and their caregivers’ needs were addressed by the hospice staff during the last days of life

Hospice Compare Web Site CMS reiterated in this final rule that the Hospice Compare Web site will, in time, feature a star rating system of 1 to 5 stars for each hospice. Hospices will have prepublication access to their own agency’s quality data, which enables each agency to know how it is performing before public posting of data on the Hospice Compare Web site

Palliative Care Hospice