1. Circle of Care Judy Girouard, RN
Regional Vice President for Life Care Centers of America
Phyllis Peterson, RN
Director of Nursing Services Life Care of Plymouth
February 7, 2013

2. Medicare Payments In 2010 Inpatient Hospital 39 130
(Percentage) (Dollars in Billions)
Inpatient Hospital
Physician Services
Outpatient
Skilled Nursing Facility
Home Health Agency
Hospice
Total 2010 Medicare Expenditures:331 Billion

3. Program Goals Reduce preventable hospital readmissions
Safe transition from SNF to home
Provide lower cost, high quality alternative to acute care setting
Provide patient-centered care

4. SNF Rules Of Participation
Part A (Hospital Insurance)
Qualifying Hospital Stay – Inpatient hospital stay of 3 consecutive midnights
Doctors orders for skilled services
Skilled care required daily
Up to100 day episode of care

5. Medicare SNF Qualifying 3-Day In-Patient Hospital Stay
Required for traditional Medicare Fee For Service under Part A
Exceptions:
Medicare Advantage (Part C)
Tufts, Fallon, Blue Cross Blue Shield, etc.
PACE-Program of All Inclusive Care for the Elderly
SCO (Dual Eligible)-Senior Care Options
MGH Waiver Program

6. Sensitive Admissions UTI Dehydration Pneumonia COPD CHF Diabetes
Hypertension

7. Home Health Care Rules Of Participation
Part A (Hospital Insurance)
Services provided under a plan of care established & reviewed regularly by a physician
Require one or more of the following
Skilled nursing care less than 7 days/week
PT, OT or ST
Certified homebound by physician
Up to 60 day episode of care; 30 day window

8. Home Health Care-Services Covered By Medicare
Services provided under a plan of care established and reviewed regularly by a doctor
Require one or more of the following Intermittent skilled nursing care PT, OT, or Speech
Certified homebound by doctor
Up to 60 day episode of care

9. Home Health Care-Services Not Covered By Medicare
24 – hour-a-day care at home
Meals delivered to home
Homemaker Services
Personal Care (bathing, dressing and using the bathroom) when this is the only required care

10. Successful Home Health Care Progams
Communicate with Skilled Nursing Facility and PCP
Provides Consistent Care Givers
Telemedicine – Early symptoms recognition and monitoring

11. Frequent Causes Of Rehospitalization
Mismanagement of medications
Moderate to severe functional impairment
Inadequate patient/family education
Lack of family safety net
Comorbidities
Patient reluctant to allow care givers in home
Failure to keep follow up appointments
Poor diet, insulin management
Substance abuse

12. Keys To Safe Transition Home
Discharge planning starts on admit date
Communication with patient, family, PCP and home health agency
Care management meetings with patient, nursing, therapy and case management
Discharge meeting with home health care
Family and Patient education
PCP notification – medication, lab, pending tests and any special needs
Electronic medical records

13. Life Care Discharge Planning
C.O.A.C. H.
Communicate Expectations
Organize goals
Assign coach
Continued review
Handoff homework

14. SNF/Home Health Care Agency Coordination Of Care
Home Health Care Agency (HHCA) Case Manager
Reviews patient chart w/SNF Interdisciplinary Team (IDT)
Attends Discharge Planning Meeting at SNF
Coordinates required services (Nursing, Therapy, etc.) with IDT
SNF Case Manager
Schedules Home evaluation
Orders DME
Provides education to family care givers

15. SNF/Home Health Care Agency Coordination of Care
Conducts follow up calls with patient/family (within 48 hours)
Seek feedback-How patient is succeeding at home
Follow up on patient concerns
Provide over the phone education
Assist in providing additional/services if needed
Readmit to facility within 30 days (3 day inpatient hospitalization not required)

16. Coordinate Circle Of Care Program
Include home health care providers in the discharge process
Educate home health care work force on SNF rules of participation, clinical capabilities, positive patient outcomes
Create an image; the SNF is part of the continuum
Common names; Rehab, Short Stay, Post Acute, Transitional Care
Section 87 State Health Care Reform Law

17. Coordinate Circle Of Care Program
Coordinate readmission process between home health nurses and SNF
Track & trend outcome data and communicate results with stakeholders
Expand Circle Events to include direct admits from physician offices and emergency rooms when appropriate
Proposed State waiver of qualifying hospital stay