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

2. 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

3. 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

4. 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

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

6. 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)

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

8. 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

9. 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

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

11. 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.

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

13. 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

14. 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

15. 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

16. 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

17. 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.

18. 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

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

20. 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

21. 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

22. Palliative Care
Hospice