Community Resources
Linda Cragin, Director
MassAHEC Network
4-26-2013
Today’s Objectives
• Understand the importance of care
transitions
• Understand the range of community
services available.
• Understand how to access community
services.
• Understand the important role of
informal/family caregivers.
Care Transitions:
• Better coordination of patient transfers
among care sites and the community
could save money and improve care.
• Care transition describes a continuous
process as patient care shifts from one
setting to another.
www.healthaffairs.org
Care Transitions:
• Hospitalizations account for approximately 33% of
total Medicare expenditures ($524 billion in 2010)
and represent the largest program outlay.
• The Medicare Payment Advisory Commission
estimated Medicare costs of approximately $15 billion
due to readmissions, $12 billion of which is for cases
considered preventable.
• Other estimates range from $25 to $45 billion in
wasteful spending (2011) due to avoidable
complications and unnecessary hospital admissions.
www.cfmc.org, www.healthaffairs.org
Within 30 days of
discharge,
19.6 % of Medicare
beneficiaries are rehospitalized.
Jencks SF, Williams MV, Coleman EA:
Rehospitalizations among patients in the Medicare
Fee-for-service Program. NEJM 2009 Apr 2;
360(14):1418-28
ACA impact on Transitions
• Effective 10/1/12:
- Increase Medicare payments if hospitals
achieve/exceed targets for certain quality
measures – including discharge
processes and instruction
- Reduce Medicare payments by 1% if
readmission rates readmissions rates
exceed a target for certain diagnoses.
Care Transitions:
Patient and Caregiver Involvement, Medication
reconciliation, Handoff communication and
Discharge, Preparing patients for Discharge,
Teamwork and Interdisciplinary Rounds, etc.
Collaboration between the hospitals
and their community partners to
effectively co-design better
processes of patient transfer.
The Care Transitions Program® - Transition Coaches® work with
patients with complex needs and coach them with self-management
skills to ensure their needs are met during transition from hospital to
home.
So where do patients go?
Rehab Hospital
• intensive inpatient rehabilitation
therapy
• specialized care (3+ hours of
therapy a day) from a team (MD,
RN, PT/OT)
• Patient must have improvement
potential: stroke, spinal cord, brain
injury
• Less likely: hip fracture, knee
replacement unless there are
complications
• Coverage: Medicare Part A
Skilled Nursing/Extended Care
Facilities:
• Medicare covers skilled care for 120-100 days
• Medicaid, long term care
insurance and private payment for
long term/chronic/extended care.
• Team based care: Nursing, PT,
OT, ST, SW, Recreational
Therapist, pharmacist consultant,
medical director
• Scheduled interprofessional care
planning meetings with
patient/family involvement.
SNF Medicare Coverage:
• Patient was formally admitted as an inpatient to a
hospital for at least three consecutive days in the
30 days prior to admission in a Medicare-certified
skilled nursing facility (not ER observation!); and
• Medicare Part A covered the hospital stay
• Patient needs skilled nursing care seven days a
week or skilled therapy services at least five days
a week.
Critical opportunity for better transitions planning
Home Health Services:
Skilled, Intermittent, Homebound
• Max: 8 hours/day and 28 hours/week.
• Skilled nursing: performed by a
licensed nurse
Injections (and teaching patients to self-inject),
tube feedings, catheter changes, wound care, etc.
• Home health aide: if patient requires
skilled services.
Includes help with bathing, toileting, dressing, etc.
• Skilled therapy: performed by a licensed
therapist
PT: gait training, regain/maintain movement and
strength
ST: regain and strengthen speech and language
OT: regain/maintain the ability to do ADLs
• Medical social services
• Coverage: Medicare Part A, no
deductible/co-insurance
Outpatient PT, OT, ST
• Medically necessary
• Medicare: if improvement or to
prevent deterioration
• Limits! Medicare will cover up to $1,880
for physical and speech therapy
combined, and another $1,880 for
occupational therapy.
• If patient approaches the limit and
needs more, MD can tell Medicare
that it is medically necessary
• Coverage: Medicare Part B
Hospice:
• MD: life expectancy is <6 months
(ALOS is 7 days!)
• Patient signs electing palliative care
• Patient does not need to be
homebound
• Comprehensive services delivered
by a team: RN, PT/OT/ST, pastoral care,
social work, volunteers, respite, music and
art therapists, massage, etc.
• Benefit includes two 90-day benefit
periods followed by an unlimited
number of 60-day benefit periods.
• Coverage: Part A
Medicare Advantage Plans
• Health Maintenance Organizations (HMO)
• Preferred Provider Organizations (PPO)
• Private Fee-For-Service (PFFS) plans.
• Special Needs Plans (SNP)
• Provider Sponsored Organizations (PSO)
• Medicare Medical Savings Accounts (MSAs)
In Massachusetts:
Senior Care Options (SCOs)
Integrated Care Organizations (ICOs)
Program for All Inclusive Care for the Elderly (PACE)
Evercare
Some blend Medicare and Medicaid coverage…
Community Resources
Community Resources
• 1-800-age-info www.800ageinfo.org
Community Resources:
• Assisted Living and Supportive Housing
• Aging Services Access Points (in MA)
• Social Day Care or Adult Day Health
• Transportation
• Councils on Aging/Senior Centers
• etc.
Family Caregivers
• Family caregivers are the foundation of long-term
care nationwide.
• More than 65 million people, 29% of the U.S.
population, provide care for a chronically ill, disabled
or aged family member or friend during any given
year and spend an average of 20 hours per week.
• The value of these “free” services is estimated to be
$375 billion a year; almost twice as much as is
actually spent on homecare and nursing home
services combined ($158 billion).
National Alliance for Caregiving 2009 various studies
Home Care, Nursing Home Care,
Family Caregiving and
National Health Expenditures, U.S. 2004
Billions of Dollars
$1,878
$306
$43
$115
Home Care Nursing Home Economic Total National
Care
Value of
Health
Informal
Expenditures
Caregiving
(midrange)
Expenditure data from Office of the Actuary, CMS, Smith C, et al., Health Affairs. 2006;25.
The typical family
caregiver:
• A 49-year-old woman caring for her widowed 69year-old mother who does not live with her.
• She is married and employed.
• Approximately 66% of family caregivers are women.
• More than 37% have children or grandchildren under
18 years old living with them.
National Alliance for Caregiving 2009
Summary:
There are many community resources…
There are skilled, trained, professional staff
caring across the spectrum of services…
Communication and coordination is critical…
Patient and family involvement is a must…
And… remember:
1-800-age-info www.800ageinfo.org