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
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.
PROCESS
• Review venues of care available for
inpatients at time of discharge
• Review strategies and techniques to ensure
timely and appropriate discharge.
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
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
How much service will Medicare
pay for?
Services that are:
• part-time,
• intermittent,
• “skilled”
• Not “24/7 ” home care
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
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
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 nonmedical 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
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
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
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
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.
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.
Acute Rehabilitation
How to qualify?
QUALIFIERS
• Re habilitatable?
• “RE-H-AB”mnemonic
is the patient reasonably
expected to improve
• Inpatient 3 nights
• H elp?;
Examples; Immanuel,
will the treatment help?
Madonna
• AB le;
can the patient cooperate
• When in doubt, consult physiatrist
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.
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)
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.
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
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, oncall 24/7 and occasionally short-term
continuous home care.
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
HOSPICE SERVICES
Interdisciplinary team
• R.N.
• Attending Physician
• Hospice Medical Director (physician)
• Chaplain
• Social worker
HOSPICE SERVICES continued
• Bereavement for caregivers
• Volunteers
• Durable Medical Equipment
such as a hospital bed, commode, special wheelchair, and
other special assistive devices.
At time of admission to hospital your
elderly patient faces discharge to one
of the following:
• Home with
informal support58%
• 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%
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
Questions?
Next;
Review strategies and techniques to ensure
timely and appropriate discharge.
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
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
Define discharge by Goals rather
that Time
• “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
ADL’s appropriate for discharge
disposition
ADL’s & expectations • D ress
How to remember the • E at
ADL’s that will
•
A
mbulate
affect my patient?
D-E-A-T-H
• T oilet/Transfer
• H ygeine
• ADL needs and Placement
ADL
Home
Care
Acute
Rehab.
SNF
LTAC
Hosp.
D ress
+/-
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E at
+
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A mbulate
+
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T ransfer
+
T oilet
H ygiene ------
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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
• Early SW involvement
• Disposition
discussions by
physician
“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
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.
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
END OF SHOW
• Questions?
• Additional References
www.hcfa.gov/medlearn/default.htm
• ( basic coding, assist with claims)