Vinh Nguyen, MD, MBA
Assistant Clinical Professor
Division of Geriatric Medicine and Gerontology
Department of Family Medicine
University of California, Irvine
FUNCTIONAL ASSESSMENT AND
DETERMINATION OF LEVELS OF CARE
IN OUR GERIATRIC PATIENTS
OBJECTIVES
Functional tools for assessing the older adult.
 Using tools to work on your plan of care.
 Understand physical performance tests pertinent
to the older adult.
 Know different levels of care available.
 Understand some basics of CMS coverage for
resources.
 Use knowledge of levels of care to optimize your
patient outcomes.
 Plan ahead for patient disposition planning.

ADL AND IADL

Activities of Daily Living







Feeding
Grooming
Continence
Toileting
Ambulation
Dressing
Bathing

Instrumental Activities of
Daily Living








Telephone
Cooking
Housework
Laundry
Transportation
Shopping
Medications
Finances
KATZ AND
LAWTON
SCALES
Image from: http://consultgerirn.org/uploads/File/trythis/try_this_23.pdf
SOCIAL HISTORY


Not just T/E/D
Gather a thorough social history




Family
Caregiver assistance
Caregiving for others
Home setting







Apartment/Condo/Home
Number of stories
Steps in or out
Safety at home
Language and culture
Education
Profession or prior work
PHYSICAL PERFORMANCE TESTING

Gait
 Get
up and go test
 10
feet
 Time?
 Gait
speed
 >0.8-0.9
m/s: community independence
 >0.6m/s: community ambulation sans WC
 Tinetti

Balance and Gait
Grip strength
LEVELS OF CARE
Post hospitalization AKA “Disposition”
 Multi-disciplinary approach

 Physical/Occupational/Speech
Therapy
 Social
work
 Patient’s wishes
 Family and friends

Planning, planning, planning…
POST ACUTE CARE
Type
Description
Payor
Basis for Medicare
Payment
Cost Range $ per day
Physician Type
Acute Inpatient Rehab
3 hours of PT/OT per
day. High intensity
rehabilitation.
Medicare Part A
Medicaid
Payment per episode
of care based on
complexity
1000-2000
PM&R
Skilled Nursing Facility
Skilled needs can
include variety of
things including
medications, wound
care, rehab, etc.
Medicare Part A
Medicaid
Daily rate, first 20 days
paid by Medicare then
day 21 to 100 80% is
paid and 20% by
patient.
150-300
PCP
Long-term acute care
hospital
Medicare facility for
handling complex
patients such as
ventilator
care/weaning, critical
care patients needing
more frequent
physician followup
Medicare Part A
Medicare Diagnosis
Related Group
1500-3000
Hospitalist
Home health care
Medicare certified care
run by nurses as well
as PT/OT/ST/SW
Medicare Part A (DME
on Part B)
Payment per episode
of care based on
complexity
100-300
PCP
Medicare Part B
Medicaid
Pay per visit
100-200
PCP
Medicare Part A
Medicare Part B
Payment per day
200-300
PCP or palliative care
specialist
Outpatient Rehab
Hospice and Palliative
Care
Terminal illness with
focus on nonhospital
care and symptom
management AND
active support like
hospicebut without
expectation of avoiding
further medical care.
Adapted from JAMA, 01/19/2011-Vol305, No.3 “Finding the Right Level of Posthospital Care”, Robert L. Kane, MD.
LONG TERM CARE
Type
Description
Payor
Basis for Medicare
Payment
Cost Range $ per day
Physician Type
Home care/Personal
care
Services for frail
persons needing help
with ADL or IADLs
Medicaid. Ex. IHSS
Per hour payment
75-150
PCP
Nursing Home
Certified for long term
care. Special units?
Medicaid
Payment per day
75-300
PCP
Assisted living
Institutional care with
apartment like living
quarters and some
assistance on a “a la
carte” basis.
Medicaid (in some
states with vouchers)
Payment per
day/month
60-300
PCP
Day care or adult day
health centers
Community faciltiies for
centralized care for
various periods of the
day.
Medicaid (some states)
Payment per use
60-120
PCP
Adult foster care
Small group homes
with care by
nonprofesionals
Medicaid (some states)
Payment per month
50-100
PCP
Independent living
Room and board and
some housekeeping.
Community activities
and amenities like
meals.
None
50-100
PCP
Board and care
Varient of independent
living, with room and
some meals
None
Adapted from JAMA, 01/19/2011-Vol305, No.3 “Finding the Right Level of Posthospital Care”, Robert L. Kane, MD.
PCP
HOW DO YOU CHOOSE?!?
Current and prior level of function
 Therapy needs
 Psychiatric care needs
 Expectations
 Finances
 Social support
 Resources such as Center for Medicare/Medicaid
Services and Veterans Affairs. Also state and
county resources.

CASE QUESTIONS