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Welcome to
Optimizing a SNF StayKhai Nguyen, MD, MHS, HMDC
October 24, 2015UCSD 2nd Annual Geriatric Symposium
VITAS Healthcare—Hospice Medical Director VA Home-Based Primary Care – PCP UCSD School of Medicine
Geriatrics Fellowship Hospice Clinical Instructor 3rd Medical Student Geri/Hospice Lead Clinical
Instructor No ownership in any SNF or Post-Acute Care
Facility
Disclosures
Medicine- Internal Medicine/Geriatrics Board Certifications in IM, Geriatrics, HMDC
Public Health- Health Policy Emphasis Centers for Medicare and Medicaid Services
(CMS) Office of Clinical Standards and Quality Healthy Aging Project
Family member/son of a patient in a SNF for 9 months
Speaker Background
You! Patient Prospective Patient Family/Friends DPOA/Surrogate
Decision Maker Clinicians/Providers RCFE/SNFs
Intended Audience
By the end of this talk—you will: Know what a SNF is Get a better idea of what to expect in a SNF Know what to expect from a SNF Know what to expect after staying in a SNF Have a better idea of what to plan for
Objectives
SNF = Skilled Nursing Facility
Skilled Care- Qualifying hospitalization Needing “skilled care”
PT/OT/ST/RT/IV treatment/Wound Care/new tubes Custodial Care-
Longterm help with ADLs
What is a SNF?
It takes a village…
Why do we even have SNFs?
Medicare Medicaid (Medi-Cal) Private Insurance Out-of-Pocket
Who Pays for a SNF?
What Health Insurance pays for: Doctor’s visit Nurse/allied heath care Labs/Imaging/Medicines
What Health Insurance does NOT pay for: Non-emergent transportation Caregiving Room & Board
A thing about Health Insurance…
A few constants to keep in mind… Taking your child to the Pediatrician
HI covers doctor/RN/Labs/Meds HI does NOT cover you transporting child to the
office and does NOT pay for daycare
This constant is same goes for adults HI does not cover non-emergent
transport/caregiving
Why does our HI not pay for transportation and caregiving?
So why are you at this talk?
85 y/o female with Alzheimer’s Dementia who was sent to the Emergency Room for a fall at home while trying to go to the bathroom at 3AM.
Dx: Osteoporosis Left Hip Fracture1-Year Mortality is
20-50%also a Urinary Tract
Infection
So you know someone in a SNF?
After 3 days in the hospital and orthopedic surgery
Cannot go home yet because cannot transfer independently
Recommended to go to a Skilled Nursing Facility
So you know someone in a SNF?
“Where do we go from here?”
Home Independent Living Assisted Living Memory care/assisted living Board & Care/Group Home Nursing Home (Skilled or Custodial) Sub-Acute Care Hospitals
Continuum of Care
Prior and current level function ADLs = Activities of Daily Living
1) Eating2) Bathing3) Dressing4) Toileting5) Transferring/Walking6) Continence
The Key is ADLs
Hospital Street, USA
RCFE-Independent Living
Board & Care Land
ER-Land
Hospice Land
Home
SNF-Skilled/Custodial
EntranceExit
Planning for Life’s Health Outcomes
Advance Directives
POLST
Talk with family/surrogate decision makers
GOALS OF CARE
Ideal
Reality
Good: Rehab* Bad: Heavily regulated and punished** Ugly: Bad things can happen…***
* Depends on many factors, mainly prior level of functioning/will** Breeds a culture of fear, focus on rules not people, apathy***But can be prevented
The Good, The Bad, and The Uglyof SNF…
Caring for our elderly family/patients Who’s the Village?
Doctors Nurses (NP/RN/LVN) Therapists (PT/OT/ST/RT) CNAs MSW/Administrators FAMILY
It takes a village…
Eating Laughing Loving The Dark Side- being alone, feeling isolated
etc…
It’s a social thing…
Advanced Directive POLST TALK TO YOUR FAMILY
Must Know: Goals of Care
Depersonalization of Healthcare Photos/Collage Frequent Family Visits Timely Family Visits (mealtimes and wakeup) Organize Family visits to optimize time
capital Get in the trenches Don’t be passive
Humanize the Patient!
Listen to your doctors as long as they are listening to you
Challenges: Doctors
Helping families and patients: help themselves navigate the defragmented health “non-
system” finding funding sources mental health and wellbeing everything non-medical needs
Challenges: SNF MSW
Past & Recent controversies (professionalism)
Disparity in training (Physicians vs CNA) Lack of cultural and aging health training Lack of good pay/benefits Lack of support Plethora of patients (high patient to staff
ratio)
Challenges: SNF Staff
Medical Psychosocial Financial Loss/Grief Dependence
Challenges: Patient
Change of dynamic from healthy family member and sick family member
Allowing others to help take care of your loved one
Ill-defined responsibilities
Challenges: Families
Paradigm shift SNF corporations Public Health State/County regulators Joint Comission Transparency of costs
Challenges: Society/Community
“What does love got to do with it?”
Society/social policies wants us to take care of our own!
Families step up policies And YES, be nice to your kids, they may very
well be choosing the “cheapest” SNF for you!
Love has everything to do with it!
Fear not—just plan It’s not the end of the world…yet Goals of Care Denial is a strength – Denial is a weakness
Take Away Points
SNF Stay Optimized!
THANK YOU
Questions & Discussion