1. October 30, 2012

2. (Percentage)(Dollars in Billions)  Inpatient Hospital 39 130  Physician Services 29 96  Outpatient 14 46  Skilled Nursing Facility 826  Home Health Agency 6 20  Hospice 4 13  Total 2010 Medicare Expenditures:331 Billion 2

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

4.  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 4

5. 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 5

6.  UTI  Dehydration  Pneumonia  COPD  CHF  Diabetes  Hypertension 6

7.  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 7

8.  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 8

9.  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 9

10.  Communicate with Skilled Nursing Facility and PCP  Provides Consistent Care Givers  Telemedicine – Early symptoms recognition and monitoring 10

11.  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 11

12.  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 12

13.  C.O.A.C. H. ◦ Communicate Expectations ◦ Organize goals ◦ Assign coach ◦ Continued review ◦ Handoff homework 13

14.  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 14

15.  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) 15

16.  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 16

17.  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 17