Community Resources

Linda Cragin, Director

MassAHEC Network

4-30-2012

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:

• Hospitalizations account for approximately 33 percent 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.

www.cfmc.org

Within 30 days of discharge,

19.6 % of Medicare beneficiaries are re-

hospitalized.

Jencks SF, Williams MV, Coleman EA: Rehospitalizations among patients in the Medicare Fee-for-service Program. NEJM 2009 Apr 2; 360(14):1418-28

Care Transitions:

Hospitals have traditionally served as the focal point of efforts to reduce readmissions by focusing on those components that they are directly responsible, including the quality of care during the hospitalization and the discharge planning process.

… multiple factors along the care continuum that impact readmissions, and identifying the key drivers of readmissions for a hospital and its downstream providers is the first step towards implementing the appropriate interventions necessary for reducing readmissions.

www.cfmc.org

Care Transitions: BOOST

Better Outcomes for Older Adults through

Safer Transitions:

•Patient and Caregiver Involvement•Concerns following discharge/Reengineering systems•Medication reconciliation•Adverse events after discharge•Handoff communication and Discharge•Readmission•Preparing Patients for Discharge•Teamwork and Interdisciplinary Rounds

STAAR:

STAAR hospital- community teams focus on the implementation of four key process-level improvements that require extensive collaboration between the hospitals and their community partners to effectively co-design better processes:

STAAR:

1. Perform an Enhanced Assessment of Post-Hospital NeedsA. Involve family caregivers and community providers as full partners in

completing a needs assessment of  patients’ home-going needs.B. Reconcile medications upon admission.  C. Create a customized discharge plan based on the assessment.

2. Provide Effective Teaching and Facilitate Enhanced LearningA. Customize the patient education materials and processes for patients and

caregivers.B. Identify all learners on admission.C. Use Teach Back regularly throughout the hospital stay to assess the patient’s

and family caregivers’ understanding of discharge instructions and ability to perform self-care.

 

STAAR:

3. Provide Real-time Handover CommunicationsA. Reconcile medications at discharge.B. Provide customized, real-time critical information to next provider(s).C. Give patients and family members a patient-friendly discharge plan.D. For high-risk patients, a clinician calls the individual listed as the patient’s

emergency contact to discuss the patient’s status and plan of care.

4. Ensure Timely Post-Hospital Care Follow-UpA. Identify each patient’s risk for readmission.B. Prior to discharge, schedule timely follow-up care and initiate clinical and

social services based upon the risk assessment.

So where do patients go? Who needs to be involved in transitions planning?

Rehabilitation Hospitals

Skilled Nursing Facilities/Long Term Care

Home Health Services

Outpatient Rehab

Hospice

Other community resources

Family

Rehabilitation Hospitals:• specialty hospitals (or parts of acute care hospitals)

that offer intensive inpatient rehabilitation therapy• require a high level of specialized care (3+ hours of

therapy a day) from a team (MD, RN, PT/OT) that cannot be provided in another setting

• stroke, spinal cord, brain injury…with improvement potential!

• less likely: hip fracture, knee replacement unless there are complications

• Coverage: Medicare Part A

Skilled/Extended Care Nursing Facilities:• Medicare covers skilled care for 1-20-100 days• Medicaid, long term care insurance and private

payment for long term/chronic/extended care.• Team based approach to care: Nursing, PT, OT, ST,

SW, Activities/Recreational Therapist, pharmacist consultant, medical director

• Other resources: clergy, volunteers, etc.• Scheduled interprofessional care planning meetings

with patient/family involvement.

Skilled/Extended Care Nursing Facilities:• Medicare: Patient needs skilled nursing care

seven days a week or skilled therapy services at least five days a week.

• 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• Critical opportunity for better transitions planning

Home Health Services: Skilled, Intermittent, Homebound

• No more than 8 hours per day and 28 hours per week. • Skilled nursing: can only be performed by a licensed nurse.Injections (and teaching patients to self-inject), tube feedings, catheter changes,

observation/assessment, care plan management/evaluation, wound care, etc.

• Home health aide: if patient requires skilled services. Includes help with bathing, toileting, dressing, etc.

• Skilled therapy: can only be performed by a licensed therapist:PT: includes gait training and supervision of and training for exercises to

regain movement and strength

ST: include exercises to regain and strengthen speech and language skills.

OT: to regain the ability to do usual daily activities: eating and dressing.

• Medical social services: social and emotional concerns• Coverage: Medicare Part A, no deductible/co-insurance• Critical for connection for transitions planning

Home Health cont…• Medical supplies: certain supplies provided by the

Medicare-certified home health agency, such as wound dressings and catheters.

• Durable medical equipment (DME): 80% of Medicare-approved amount for equipment such as a wheelchair or walker.

• Nothing covered in the bathroom!!! • Can sometimes get loaner equipment. • Elders are creative and share!

Outpatient PT, OT, ST

• Medically necessary with a plan of treatment periodically reviewed by MD

• Medicare will only cover therapy if improvement or to prevent deterioration

• Limits! 2012: 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:• Hospice medical director (and patient’s doctor) certify

that a terminal illness (life expectancy is <6 months)• Patient signed statement electing to have Medicare

pay for palliative care such as pain management, rather than care to try to cure your condition

• Terminal condition is documented in medical record• Receive care from a Medicare-certified hospice• Patient does not need to be homebound. The benefit

is a comprehensive set of services delivered by a team of providers.

Hospice cont…• Comprehensive services: RN, PT/OT/ST, pastoral

care, social work, volunteers, respite, etc. • Benefit includes two 90-day benefit periods followed

by an unlimited number of 60-day benefit periods.Starting April, 1, 2011, patient must have a face-to-face meeting with a hospice MD or NP if reaches 3rd benefit period. Continued meetings on a prescribed schedule.

• Coverage: “original Medicare” 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)

Program for All Inclusive Care for the Elderly (PACE)

Evercare

Some blend Medicare and Medicaid coverage…

Community Resources

• 1-800-age-info www.800ageinfo.org• Aging Services Access Points (in MA)

- Family Caregiver program- Assessment for in-home services

- A homemaker for cleaning and meal prep- A home health aide for personal hygiene

• Social Day Care or Adult Day Health• Transportation

Community Resources:

• Assisted Living and Supportive Housing• Councils on Aging/Senior Centers- a

city/town run center – social, recreational, information and referral, meals, etc.

• Y M/W CA’s – wellness/exercise programs • RSVP- Retired Senior Volunteer Program• SCORE – Senior Corps of Retired Executives• Money Management programs, AARP tax

assistance, 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

$43 $115$306

$1,878

Home Care Nursing HomeCare

EconomicValue ofInformal

Caregiving(midrange)

Total NationalHealth

Expenditures

Expenditure data from Office of the Actuary, CMS, Smith C, et al., Health Affairs. 2006;25.

Bill

ion

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f D

olla

rs

The typical family caregiver:

• A 49-year-old woman caring for her widowed 69-year-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

Family Caregiving by State, 2004

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