Discharge Planning. Home Care 1. Objectives. Where are they Going?

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Discharge Planning

Heidi White, MD

Associate Professor of Medicine

Yvonne Spurney, RN

Associate Chief Nurse

Cristina C. Hendrix, DNS, GNP-BC

Associate Professor of Nursing

Objectives

• Describe challenges of care transitions and consequences of poor transitions.

• Describe role of physicians and other providers in optimizing care transitions

• Outline the financing of post-hospital care

• Describe the major discharge options for older adults and what services are provided, including unique resources in the Durham Community

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Discharge Planning Process

• All team members should participate • Begin early

• Documentation

• Post-hospital site and care appropriate and ready

• Physician needs to lead • Resources

Transitional Care

• Ensures coordination and continuity of care • Care plan and availability of information about the patient's goals, preferences, and clinical status.

• Includes:

– Logistical arrangements

– Education of the patient and family

– Coordination among the health professionals involved in the transition

Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7.

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Why should we care about poor

transitions?

Medication discrepancies

14-30% of patients discharged from hospital to home experienced ≥ 1 medication discrepancies; 30 d re-hospitalization rate among patients with identified discrepancies (14.3%) higher than patients without (6.1%) (P=0.04)a

In 86% of NH transfers, at least one medication order was altered (mean 1.4); 20% of changes resulted in an adverse eventb

aColeman et al. Arch Intern Med 2005; 165:1842-47; Kwan Y et al. Arch Intern Med 2007;167:1034-40

bBoockvar KS, Fishman E, Kyriacou CK et al. Arch Intern Med 2004;164:545-50.

Why should we care about poor

transitions?

Medication discrepancies

14-30% of patients discharged from hospital to home experienced ≥ 1 medication discrepancies; 30 d re-hospitalization rate among patients with identified discrepancies (14.3%) higher than patients without (6.1%) (P=0.04)a

In 86% of NH transfers, at least one medication order was altered (mean 1.4); 20% of changes resulted in an adverse eventb

aColeman et al. Arch Intern Med 2005; 165:1842-47; Kwan Y et al. Arch Intern Med 2007;167:1034-40

bBoockvar KS, Fishman E, Kyriacou CK et al. Arch Intern Med 2004;164:545-50.

Inadequate follow-up care post-hospitalization Total

No. (%)

Completed

Workup Type Yes No

Diagnostic procedure 115 (47.9) 50.4 49.6 Subspecialty referral 85 (35.4) 72.6 27.4 Laboratory test 40 (16.7) 85.0 15.0 Total 240 (100) 64.1 35.9

Moore C et al. Arch Intern Med 2007.

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Hospital to PCP transfer

• Direct communication between hospital

physicians and primary care physicians occurred infrequently

• Discharge summary

– Availability at first postdischarge visit low (12%-34%) – Remained poor at 4 weeks (51%-77%)

– Affected quality of care in ~25% of follow-up visits – Often lacked important information (e.g., lab results,

discharge medications, treatment, follow-up plan)

Kripalani S, et al. JAMA 2007;297:831-41.

In summary, ineffective transitions

lead to

• Wrong treatment • Delay in diagnosis • Severe adverse events • Patient complaints • Increased healthcare costs

Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature Review Report. March 2005. Available www.safetyandquality.org/internet/safety/publishing.nsf/Content/ AA1369AD4AC5FC2ACA2571BF0081CD95/$File/clinhovrlitrev.pdf

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Durable Medical Equipment needed?

• Covered by

Medicare (mostly) • Specific

Requirements

Courtesy of Jeremy Boal, MD

What Non Durable Equipment is needed?

• Adult Incontinence Supplies • Booties • Gloves

• Wound care supplies (covered by Medicare if CHHA involved-supplied by CHHA as well) • Not covered by

Medicare

• Usually covered by Medicaid

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How will my patient obtain, understand, and manage medication?

What obstacles await my patient at home?

Discharge Planning Process

• Ideally, all team members should

participate—begin early

• MD should provide D/C summary and orders, including med reconciliation

• Site of care after D/C should be warranted by Patient’s needs and abilities

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Who Pays?

Payment System

Medicare (Title XVIII)

65 years and older qualify

Part A: hospital care, home health services or skilled nursing care,

and hospice

Part B: physician visits, durable medical equipment

Monthly fee

Part C Part D

Medicaid (Title XIX)

Medical assistance for people with limited resources Level of state participation varies

All states must pay for nursing home care

What Does Medicaid Cover?

 Doctor Bills  Hospital Bills

 Prescriptions (Excluding prescriptions for Medicare beneficiaries)

 Vision Care  Dental Care  Medicare Premiums  Nursing Home Care

 Personal Care Services (PCS), Medical Equipment, and Other Home Health Services

 In-home care under the Community Alternatives Program (CAP)

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Sites of Post Hospital Care

Site Requirements Funding

Inpatient rehab Pt can tolerate 3 hours of rehab/d requiring multiple disciplines (e.g. PT/OT/ST) Medicare Part A pays 100% for days 1-20 copay for days 21-100 with Part A covering the rest pt pays 100% after day 100

Select Specialty Hospital - Durham

• 24-hour Respiratory Therapists

• ACLS Certified Nursing Care

• Case Management and Discharge Planning • Clinical Pharmacy Services

• Daily Physician Visits • Vent Weaning • Beriatric Care

Sites of Post Hospital Care

Long-term Acute Care (LTAC)

Complex med needs. Hosp level but not that sick; too sick for SNF ~20-30 days e.g. vent wean; IV Abs

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Sites of Post Hospital Care

Skilled Nursing Facility (SNF) Pt requires skilled nursing care can’t tolerate 3 h of therapy/d 2 skilled needs 3 hospital overnights Medicare Part A 100% of charges for days 1-20 copay ($141.50 in 2011) days 21-100 pt pays 100% after day 100

Post Hospital Care in the Nursing Homes

• Response to reduced length of stay in acute care • Integrates features of acute care/rehab focused • Interdisciplinary staffing

– Nursing: RN, LPN, CNA, wound care – Therapies: PT/OT/ST, nutrition, SW, etc – Medical: MD, PAs, NPs

– Other clinical: dental, podiatry, vision, psych, psychology, clinical pharmacist

Ancillary Services in the Nursing Home

• Phlebotomy/Laboratory

• Radiology • EKG

• IVs: peripheral, PICC, etc • Echocardiography/Holter monitors • No Dobhoffs or Central Lines • Can have PEGs

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Interface of Acute and Long term Care

• Most nursing-home residents are admitted from an acute-care hospital

• Suboptimal information transfer is common – Summaries, meds omitted/changed, advance directives,

psychosocial issues • High Readmission Rates

– CMS research found that approximately 45% of hospital admissions among those receiving either Medicare skilled nursing facility services or Medicaid nursing facility services could have been avoided, accounting for 314,000 potentially avoidable hospitalizations and $2.6 billion in Medicare expenditures in 2005.

Sites of Post Hospital Care

Site Requirements Funding

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Candidates for Home Health:

• Care of a pressure or venous stasis ulcer • Physical therapy for a hip fracture

• PT and Occupational therapy after a stroke • Family and patient education regarding

diabetic monitoring and management • Monitoring of vital signs and other clinical

parameters in a patient with a CHF exacerbation

• Home safety evaluation Courtesy of Jeremy Boal, MD

Once skilled service has been

established other services may

also be available:

• Social work

• Home health aide services

• Occupational therapy (can stay open)

• Nutrition

Sites of Post Hospital Care

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What Medicare Doesn’t Pay For

• Home Health Aide

– Medicare funded – Short duration – Pt. must have

concurrent acute skilled care

– A few hours per day – Full range of ADLs – From Certified Home

Health Agency (CHHA); VN supervision • PC Homemaker – Chronic duration – No need for concurrent acute skilled care

– IADLs & light ADLs – Authorized by Area

Agency on Aging (AAA)

– Funding from

Agency on Aging

Housing Alternatives for Older Adults

• Home

• Senior Housing

• Continuing Care Retirement Communities (CCRCs) • Assisted Living Facilities (ALFs)

• Residential Care Facilities, Board and Cares, Rest Homes

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Where did our patient go?

A) Skilled Nursing Facility (SNF)/Subacute Rehab-Nursing Home

B) Acute Rehab--Inpatient Rehab C) LTAC

D) Long Term Care E) Home with home health F) Hospice

Was that the right disposition?

Information

 Government web sites

 www.medicare.gov/nhcompare/home.asp

 Triangle J Area Agency on Aging

http://www.tjaaa.org/  BenefitsCheckUp https://www.benefitscheckup.org/  Community specific  Senior PharmAssist http://www.seniorpharmassist.org/

 Other web sites (eg OAA, AARP,

Commonwealth Foundation)