1. VENUES OF POST-HOSPITAL CARE Or “Where, Oh Where Will My Patient Go Next”? Ed Vandenberg MD CMD Bill Lyons, M.D. UNMC Geriatrics & Gerontology

2. Objectives Upon completion the learner will be able to : Describe best processes for appropriate and timely discharge, placement and post-acute care List Medicare patient qualifiers for post acute venues of care Describe patient characteristics that will define appropriate placement post hospital.

3. PROCESS Review venues of care available for inpatients at time of discharge Review strategies and techniques to ensure timely and appropriate discharge.

4. At time of admission to hospital your elderly patient faces discharge to one of the following : Home with informal support Home with Home Health Care Skilled Nursing Facility (SNF) Nursing Home care Acute Rehabilitation Long Term Acute Care Hospital Hospice

5. Home with Home Health Care Appropriate patient consenting patients whose medical needs can be safely managed at home when: The required time, financial, physical and emotional resources have been considered. Medicare Qualifiers reasonable and necessary” for the treatment of an illness and injury” and Requires Skilled Services and HOME BOUND

6. How much service will Medicare pay for? Services that are: part-time, intermittent, “skilled” Not “24/7 ” home care

7. Skilled Services Registered Nurse Physical therapist Speech therapist Other services may be added only if one of the 3 above skilled services are needed Example: -Social work -Home health aide -OT

8. Homebound The Definition Leaving home requires considerable and taxing effort. And Patient needs: supportive devices such as crutches, canes, wheelchairs and walkers or the use of special transportation or the assistance of another person or if the condition is such that leaving the home is medically contraindicated

9. The Definition of Homebound -continued Note: the HOMEBOUND can leave home if: the absences from the home are infrequent * or for periods of relatively short duration or for the purpose of receiving medical treatment. *Infrequent is often interpreted as once a week for non- medical outings) Medical outings can be often as needed and does not affect homebound status e.g. dialysis can be 3 or more times per week

10. Skilled Nursing Facilities (SNF) Where provided: Nursing homes that are Medicare certified Qualifiers: Hospital Inpatient 3 nights Moderately complex medical problem Medicare pays for: 100 days

11. SNF Reimbursement –The nursing home determines eligibility for Medicare benefits and assumes the financial responsibility if they determine the benefits incorrectly. –Medicare pays 100% for the first 20 days and 80% for the remaining 80 days. –100 days of benefit is renewed when the resident has not been in a hospital or SNF for 60 days in a row and has now re-entered a hospital for 3 nights in a row. Konetzka, et al. 2006 http://www.ohca.com/docs/medicare_coverage.pdf

12. Skilled Nursing Facilities Moderately complex Examples: IV’s, IM injections Feeding tubes Dressing changes (usually more than simple) Restorative care ( care and teaching by licensed nurse) (e.g care & training on: ostomy care, feeding tube care, wound care, etc. Rehabilitation

13. Skilled Nursing Facilities Services –SNF must provide: (required) –Rehabilitation services –24-hour skilled nursing services Services that SNFs might provide: (not required) –Memory support, Ventilator units, Subacute care HCP visits; - Physician first visit within 30 days admit - Physician/Mid-level alternate every 30 d x 3 then every 60 d.

14. Acute Rehabilitation Hospitals Qualifiers: must be a Medicare certified facility. must require intense, multi-disciplinary rehabilitation supervised by a physician with experience or training in rehabilitation medicine. (Physiatrist) care must be reasonable and necessary and not available at a less skilled level of care. Patient requires & can perform ~three hours of therapy each day Licensed as a hospital Rehab experts can focus on "real life" skills.

15. Acute Rehabilitation How to qualify? QUALIFIERS “RE-H-AB”mnemonic Inpatient 3 nights Examples; Immanuel, Madonna Re habilitatable? is the patient reasonably expected to improve H elp?; will the treatment help? AB le; can the patient cooperate When in doubt, consult physiatrist

16. Long Term Acute Care Hospital (LTACH) Licensed as a hospital Intensive nursing care and high-tech support Medically unstable adults with complicated injuries or illnesses. LTACH is a “hospital within a hospital”. This setting is reimbursed like any other hospital but is specialized for the complex patient requiring extended care.

17. Long Term Acute Care Hospital (LTACH) For: Medically complex Clinical & ancillary support services on site Qualifiers: Expected LOS: 25 days or more Pt’s condition requires; –Frequent physician monitoring –Highly Skilled level of care Where in Omaha: “Select Hospital” “Select Hospital” (located near Bergan Mercy Hospital)

18. Long Term Acute Care Hospital Examples Patient Types: Long term ventilators Long term parenteral antibiotics Extensive decubitus or wound care TPN Negative air flow room needs Multiple IV medications Combinations of > 4 treatments (e.g. Nebs, IV’s, wound care,) Bottom line: Ask to see if person qualifies Attendings: LTACH has list of physicians.

19. Nursing Home Care Qualifier Default (problems exceed home care, and does not qualify for any preceding venues of care) Payment Private or Medicaid or long-term care insurance

20. HOSPICE Services Goal: A good Death! Pain and symptoms management Psychological and spiritual care emphasized. Support system for caregivers before and after the death Hospice workers provide : intermittent, on- call 24/7 and occasionally short-term continuous home care.

21. HOME HEALTH HOSPICE Eligibility and Reimbursement Physician documents that the patient has six months or less to live Must have a caregiver available to provide care plan Medicare Part A, Medicaid, and most private insurances will have benefits for Hospice http://www.nhpco.org

22. HOSPICE SERVICES Interdisciplinary team R.N. Attending Physician Hospice Medical Director (physician) Chaplain Social worker

23. HOSPICE SERVICES continued Bereavement for caregivers Volunteers Durable Medical Equipment such as a hospital bed, commode, special wheelchair, and other special assistive devices.

24. At time of admission to hospital your elderly patient faces discharge to one of the following : Home with informal support- 58% Home with Home Health Care 4.3% Acute Rehabilitation 1.7% Long Term Acute Care Hospital 0.2% SNF (Medicare covered)- 23.2% Nursing home care ( non Medicare covered) 3.5%

25. REVIEW of DISPOSITIONS Home with informal support Home with Home Health Care…………………… Acute Rehabilitation…. Long Term Acute Care Hospital ………………. Skilled Nursing Facility (SNF)………………… Criteria's Homebound >3 nights, RE-H-AB Complex, >25 days Mod complex, > 3 nights

26. Questions? Next; Review strategies and techniques to ensure timely and appropriate discharge.

27. What causes delays in getting patients to appropriate and timely discharge? -Complications of hospitalization -Physician's “over estimation” of patients recovery abilities. -Patient/family “unrealistic” expectations of recovery speed and level. -“Last minute” planning

28. Physician's “over estimation” & Patient/family “unrealistic” expectations. Realism vs Unrealistic On or soon after admission: “Plan for the worst and work for the best” Discuss possible need for Home care or Rehabilitation or LTAC hospital or even NH Reduce “overestimation” errors by: Knowing discharge dispositions available Define discharge by Goals rather that Time

29. “Doctor, how long will I be in the hospital? ” TIME: “Oh 2 –3 days” Does not account for post op complications or variations in patient response GOALS “everyone is different but here are the things you will have to be able to do before you leave”. #1 Medical &/or Surgical problems Stabilized #2 ADL’s appropriate for discharge disposition

30. ADL’s appropriate for discharge disposition ADL’s & expectations How to remember the ADL’s that will affect my patient? D-E-A-T-H D ress E at A mbulate T oilet/Transfer H ygeine

31. ADL needs and Placement ADLHome Care Acute Rehab. SNFLTAC Hosp. D ress +/- --- ---- E at + + + ------ A mbulate + ------ ----- ------ T ransfer T oilet + ------ ----- H ygiene ------ ------- ------

32. Reasons & Remedies for Delays in: Discharge per Social Work Late DC planning Lack of knowledge of: -Pt’s third party payer -Family and resources -Patient’s preferences Inadequate discussion of discharge planning REMEDIES Early SW involvement Disposition discussions by physician

33. “Last minute” planning REMEDIES Involve PCP early: -Assist with coordination care. -Knows the local systems & family better -Knows the patient and can advise the patient/family on appropriate placement

34. Consult before Friday for weekend discharges to SNF or NH or Home care SNF: often won’t take on weekends unless forewarned for staffing, medications, etc Home care: always dangerous to send home on weekends due to coverage by home care with out advance planning.

35. Review  Physician's “over estimation” of patients recovery abilities.  Patient/family “unrealistic” expectations of recovery speed and level.  “Last minute” planning Remedies Realistic expectations (add ADL’s to DC planning ) Introduce reasonable alternatives early Involve SW & PCP early

36. END OF SHOW Questions? Additional References www.hcfa.gov/medlearn/default.htm ( basic coding, assist with claims)