white spurney hendrix discharge crit2014 cch · home care 1 discharge planning heidi white, md...

Home Care 1

Discharge Planning Heidi White, MD

Associate Professor of MedicineYvonne Spurney, RN

Associate Chief Nurse

Cristina C. Hendrix, DNS, GNP-BCAssociate Professor of Nursing

All Rights Reserved, Duke Medicine 2007

Objectives

• Describe challenges of care transitions and consequences of poor transitions.

• Describe role of physicians and other providers in optimizing care transitions

• Outline the financing of post-hospital care

• Describe the major discharge options for older adults and what services are provided, including unique resources in the Durham Community

Where are they Going?

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Discharge Planning Process

• All team members should participate

• Begin early

• Documentation

• Post-hospital site and care appropriate and ready

• Physician needs to lead

• Resources


Transitional Care• Ensures coordination and continuity of care

• Care plan and availability of information about the patient's goals, preferences, and clinical status.

• Includes:– Logistical arrangements– Education of the patient and family– Coordination among the health professionals

involved in the transition

Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.


Transitional care

challenges

System level

Patient level

Provider level

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Why should we care about poor transitions?

Medication discrepancies

14-30% of patients discharged from hospital to home experienced ≥ 1 medication discrepancies; 30 d re-hospitalization rate among patients with identified discrepancies (14.3%) higher than patients without (6.1%) (P=0.04)a

In 86% of NH transfers, at least one medication order was altered (mean 1.4); 20% of changes resulted in an adverse eventb

aColeman et al. Arch Intern Med 2005; 165:1842-47; Kwan Y et al. Arch Intern Med 2007;167:1034-40bBoockvar KS, Fishman E, Kyriacou CK et al. Arch Intern Med 2004;164:545-50.


Why should we care about poor transitions?

Medication discrepancies

14-30% of patients discharged from hospital to home experienced ≥ 1 medication discrepancies; 30 d re-hospitalization rate among patients with identified discrepancies (14.3%) higher than patients without (6.1%) (P=0.04)a

In 86% of NH transfers, at least one medication order was altered (mean 1.4); 20% of changes resulted in an adverse eventb

aColeman et al. Arch Intern Med 2005; 165:1842-47; Kwan Y et al. Arch Intern Med 2007;167:1034-40bBoockvar KS, Fishman E, Kyriacou CK et al. Arch Intern Med 2004;164:545-50.


Inadequate follow-up care post-hospitalization

TotalNo. (%)

CompletedWorkup Type Yes NoDiagnostic procedure 115 (47.9) 50.4 49.6

Subspecialty referral 85 (35.4) 72.6 27.4

Laboratory test 40 (16.7) 85.0 15.0

Total 240 (100) 64.1 35.9

Moore C et al. Arch Intern Med 2007.

Workup Type is the outpatient workup recommended upon discharge from the hospital. Completed indicates whether the recommended workup was done within 6 months after discharge. 240 workups recommended in 191 discharges.

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Hospital to PCP transfer

• Direct communication between hospital physicians and primary care physicians occurred infrequently

• Discharge summary – Availability at first postdischarge visit low (12%-34%) – Remained poor at 4 weeks (51%-77%)– Affected quality of care in ~25% of follow-up visits– Often lacked important information (e.g., lab results,

discharge medications, treatment, follow-up plan)

Kripalani S, et al. JAMA 2007;297:831-41.


In summary, ineffective transitions lead to

• Wrong treatment

• Delay in diagnosis

• Severe adverse events

• Patient complaints

• Increased healthcare costs

Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature Review Report. March 2005. Available www.safetyandquality.org/internet/safety/publishing.nsf/Content/ AA1369AD4AC5FC2ACA2571BF0081CD95/$File/clinhovrlitrev.pdf


HOW DO WE SUPPORT CARE TRANSITIONS?

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Durable Medical Equipment needed?

• Covered by Medicare (mostly)

• Specific Requirements

Courtesy of Jeremy Boal, MD


What Non Durable Equipment is needed?

• Adult Incontinence Supplies

• Booties• Gloves• Wound care supplies

(covered by Medicare if CHHA involved-supplied by CHHA as well)

• Not covered by Medicare

• Usually covered by Medicaid

What nutrition will be availableFor my patient?

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How will my patient obtain,understand, and manage medication?

What obstacles await my patient at home?


Discharge Planning Process

• Ideally, all team members should participate—begin early

• MD should provide D/C summary and orders, including med reconciliation

• Site of care after D/C should be warranted by Patient’s needs and abilities

• Physician needs to lead

• Resources

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Who Pays?


Payment System Medicare (Title XVIII) 65 years and older qualify Part A: hospital care, home health services or skilled nursing care,

and hospice Part B: physician visits, durable medical equipment

Monthly fee

Part C Part D

Medicaid (Title XIX) Medical assistance for people with limited resources Level of state participation varies All states must pay for nursing home care


What Does Medicaid Cover? Doctor Bills Hospital Bills Prescriptions (Excluding prescriptions for Medicare

beneficiaries) Vision Care Dental Care Medicare Premiums Nursing Home Care Personal Care Services (PCS), Medical Equipment, and Other

Home Health Services In-home care under the Community Alternatives Program

(CAP) Mental Health Care

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Sites of Post Hospital Care

Site Requirements Funding

Inpatient rehab Pt can tolerate 3 hours of rehab/d requiring multiple disciplines (e.g. PT/OT/ST)

Medicare Part A pays 100% for days 1-20

copay for days 21-100 with Part A covering the rest

pt pays 100% after day 100


Select Specialty Hospital - Durham

• 24-hour Respiratory Therapists

• ACLS Certified Nursing Care

• Case Management and Discharge Planning

• Clinical Pharmacy Services

• Daily Physician Visits

• Vent Weaning

• Beriatric Care




Long-term Acute Care (LTAC)

Complex med needs.

Hosp level but not that sick; too sick for SNF

~20-30 days

e.g. vent wean; IV Abs

Medicare

Medicaid

Some commercial

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Skilled Nursing Facility (SNF)

Pt requires skilled nursing care

can’t tolerate 3 h of therapy/d

2 skilled needs

3 hospital overnights

Medicare Part A 100% of charges for days 1-20

copay ($141.50 in 2011) days 21-100

pt pays 100% after day 100


Post Hospital Care in the Nursing Homes• Response to reduced length of stay in acute care

• Integrates features of acute care/rehab focused

• Interdisciplinary staffing

– Nursing: RN, LPN, CNA, wound care

– Therapies: PT/OT/ST, nutrition, SW, etc

– Medical: MD, PAs, NPs

– Other clinical: dental, podiatry, vision, psych, psychology, clinical pharmacist


Ancillary Services in the Nursing Home

• Phlebotomy/Laboratory

• Radiology

• EKG

• IVs: peripheral, PICC, etc

• Echocardiography/Holter monitors

• No Dobhoffs or Central Lines

• Can have PEGs

• Everything happens more slowly

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Interface of Acute and Long term Care• Most nursing-home residents are admitted from an

acute-care hospital• Suboptimal information transfer is common

– Summaries, meds omitted/changed, advance directives, psychosocial issues

• High Readmission Rates– CMS research found that approximately 45% of hospital

admissions among those receiving either Medicare skilled nursing facility services or Medicaid nursing facility services could have been avoided, accounting for 314,000 potentially avoidable hospitalizations and $2.6 billion in Medicare expenditures in 2005.




Home Health MD orders

must certify that patient is homebound

intermittent RN, PT, ST

Medicare Part A pays 100% for most professional services (e.g. PT/OT/ST) and HHA

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Candidates for Home Health:

• Care of a pressure or venous stasis ulcer• Physical therapy for a hip fracture• PT and Occupational therapy after a stroke• Family and patient education regarding

diabetic monitoring and management• Monitoring of vital signs and other clinical

parameters in a patient with a CHF exacerbation

• Home safety evaluation

Courtesy of Jeremy Boal, MD


Once skilled service has been established other services may also be available:

• Social work

• Home health aide services

• Occupational therapy (can stay open)

• Nutrition




Hospice (home or facility-based)

MD must certify that life expectancy is < 6 months

Medicare A pays for most professional svcs and meds related to terminal illness; MD services under Part B

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What Medicare Doesn’t Pay For• Home Health Aide

– Medicare funded– Short duration– Pt. must have

concurrent acute skilled care

– A few hours per day– Full range of ADLs– From Certified Home

Health Agency (CHHA); VN supervision

• PC Homemaker– Chronic duration– No need for

concurrent acute skilled care

– IADLs & light ADLs– Authorized by Area

Agency on Aging (AAA)

– Funding from Agency on Aging


Housing Alternatives for Older Adults

• Home• Senior Housing• Continuing Care Retirement Communities (CCRCs)• Assisted Living Facilities (ALFs)• Residential Care Facilities, Board and Cares, Rest

Homes• Nursing Homes

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Where did our patient go?A) Skilled Nursing Facility (SNF)/Subacute Rehab-

Nursing HomeB) Acute Rehab--Inpatient RehabC) LTACD) Long Term Care E) Home with home healthF) Hospice

Was that the right disposition?


Information Government web sites

www.medicare.gov/nhcompare/home.asp Triangle J Area Agency on Aging

http://www.tjaaa.org/ BenefitsCheckUp

https://www.benefitscheckup.org/

Community specific Senior PharmAssist

http://www.seniorpharmassist.org/ Other web sites (eg OAA, AARP,

Commonwealth Foundation)

Home Care: www.aahcp.org

white spurney hendrix discharge crit2014 cch · home care 1 discharge planning heidi white, md...

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