Community Resources Linda Cragin, Director MassAHEC Network

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: Better coordination of patient transfers among care sites and the community could save money and improve care. Care transition describes a continuous process as patient care shifts from one setting to another.

Care Transitions: Hospitalizations account for approximately 33% 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. Other estimates range from $25 to $45 billion in wasteful spending (2011) due to avoidable complications and unnecessary hospital admissions.

Within 30 days of discharge, 19.6 % of Medicare beneficiaries are re- hospitalized. Jencks SF, Williams MV, Coleman EA: Rehospitalizations among patients in the Medicare Fee-for-service Program. NEJM 2009 Apr 2; 360(14):

ACA impact on Transitions Effective 10/1/12: -Increase Medicare payments if hospitals achieve/exceed targets for certain quality measures – including discharge processes and instruction -Reduce Medicare payments by 1% if readmission rates readmissions rates exceed a target for certain diagnoses.

Care Transitions: Patient and Caregiver Involvement, Medication reconciliation, Handoff communication and Discharge, Preparing patients for Discharge, Teamwork and Interdisciplinary Rounds, etc. Collaboration between the hospitals and their community partners to effectively co-design better processes of patient transfer. The Care Transitions Program® - Transition Coaches ® work with patients with complex needs and coach them with self-management skills to ensure their needs are met during transition from hospital to home.

So where do patients go?

Rehab Hospital intensive inpatient rehabilitation therapy specialized care (3+ hours of therapy a day) from a team (MD, RN, PT/OT) Patient must have improvement potential: stroke, spinal cord, brain injury Less likely: hip fracture, knee replacement unless there are complications Coverage: Medicare Part A

Skilled Nursing/Extended Care Facilities: Medicare covers skilled care for days Medicaid, long term care insurance and private payment for long term/chronic/extended care. Team based care: Nursing, PT, OT, ST, SW, Recreational Therapist, pharmacist consultant, medical director Scheduled interprofessional care planning meetings with patient/family involvement.

SNF Medicare Coverage: 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 Patient needs skilled nursing care seven days a week or skilled therapy services at least five days a week. Critical opportunity for better transitions planning

Home Health Services: Skilled, Intermittent, Homebound Max: 8 hours/day and 28 hours/week. Skilled nursing: performed by a licensed nurse Injections (and teaching patients to self-inject), tube feedings, catheter changes, wound care, etc. Home health aide: if patient requires skilled services. Includes help with bathing, toileting, dressing, etc. Skilled therapy: performed by a licensed therapist PT: gait training, regain/maintain movement and strength ST: regain and strengthen speech and language OT: regain/maintain the ability to do ADLs Medical social services Coverage: Medicare Part A, no deductible/co-insurance

Outpatient PT, OT, ST Medically necessary Medicare: if improvement or to prevent deterioration Limits! 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: MD: life expectancy is <6 months (ALOS is 7 days!) Patient signs electing palliative care Patient does not need to be homebound Comprehensive services delivered by a team: RN, PT/OT/ST, pastoral care, social work, volunteers, respite, music and art therapists, massage, etc. Benefit includes two 90-day benefit periods followed by an unlimited number of 60-day benefit periods. Coverage: 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) Integrated Care Organizations (ICOs) Program for All Inclusive Care for the Elderly (PACE) Evercare Some blend Medicare and Medicaid coverage…

Community Resources

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Community Resources: Assisted Living and Supportive Housing Aging Services Access Points (in MA) Social Day Care or Adult Day Health Transportation Councils on Aging/Senior Centers 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 Expenditure data from Office of the Actuary, CMS, Smith C, et al., Health Affairs. 2006;25. Billions of Dollars

The typical family caregiver: A 49-year-old woman caring for her widowed 69- year-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

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: age-info