Nursing Home to Community Program: A Discharge Planning Manual

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Nursing Home to Community Program:

A Discharge Planning Manual

March 2006

Portions of this Manual may be cited on condition that proper credit is given to:

Broome County Community Alternative Systems Agency

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The purpose of the Manual is to orient the long term care

providers in Broome County to the nursing home discharge

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are involved in returning residents to community living

and to document a standard protocol for accessing and

maximizing partner resources. Veteran Broome County

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navigating the county’s long term care system.

Manual’s Purpose

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How the Manual is Organized

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Table of Contents

Manual’s Purpose

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Discharge Planning Tools (NYSDOH/OFA)

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Community Agency Referral Sources

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Frequently

Asked

Questions

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Appendix A: CASA

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Acknowledgements

Roles & Procedures of Key Partners

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Appendix B: STIC

Nursing Home To Community Overview

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Long-Term Care Payment Options

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Appendix C: Sample Forms

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Introduction

Discharge Planning Tools

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You have the right and responsibility to be involved in your plan of care. To the greatest extent possible, consumers should be active participants in developing that plan. Below are questions to help you and your family with your discharge and future health needs.

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Discharge Planning Safety Considerations

Safety Concerns that Impact an Individual Wishing to Live

in the Community

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Provision of Service Issues

Individual Capacity Issues

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Key Elements for Effective and Safe Discharge Planning to

Facilitate An Individual’s Right to Choose

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Suggested Model for Transitional Care Planning

These questions should allow the discharge planner to determine whether the patient is likely to need a more comprehensive assessment.

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Patients who fall into any of these categories should be targeted for a comprehensive assessment 2YHUWKHDJHRI 0XOWLSOHGLDJQRVLVDQGFRPRUELGLWLHV ,PSDLUHG0RELOLW\ ,PSDLUHGVHOIFDUHVNLOOV 3RRUFRJQLWLYHVWDWXV &DWDVWURSKLFLQMXU\RULOOQHVV +RPHOHVVQHVV 3RRUVRFLDOVXSSRUWV &KURQLFLOOQHVV $QWLFLSDWHGORQJWHUPKHDOWKFDUHQHHGV HJQHZGLDEHWLF  6XEVWDQFHDEXVH +LVWRU\RIPXOWLSOHKRVSLWDODGPLVVLRQV +LVWRU\RIPXOWLSOHHPHUJHQWFDUHXVH h h h h h h h h h h h h h

High Risk Screening Criteria

3DWLHQWVZKRDUHLGHQWL¿HGDV+LJK5LVNRUWKRVHIRUZKRPDPRUHFRPSUHKHQVLYH assessment is indicated should be evaluated using the following criteria. The screening

process is dynamic and may include other information not listed below.

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Screening and Assessment Flow Chart

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transition process should be initiated in the hospital, particularly for patients ZKRKDYHSODQQHGDGPLVVLRQRUDQ elective procedure

Community service providers should be SUHSDUHGWRFROODERUDWHZLWKWKH

GLVFKDUJHSODQQHUZKHQHYHURQHRIWKHLU patients/clients are admitted to another level of service, information exchange is crucial to a successful outcome

Patient Admission

Initial Discharge

Planning

Basic Discharge: No needs

outside of scripts, routine

IROORZXSDQGZULWWHQGLVFKDUJH instructions

,QLWLDOVFUHHQLQJFDQEHGRQHE\FKDUWUHYLHZ SDWLHQWUHYLHZLQWHUGLVFLSOLQDU\WHDPPHHWLQJ available demographic information, patient diagnosis and history and other methods. The purpose of this screening is to identify patients ZKRZLOOQHHGGLVFKDUJHSODQQLQJRXWVLGHRIWKH routine discharge.

6HHKLJKULVNVFUHHQLQJFULWHULD

Comprehensive

Assessment

Moderate Discharge Planning Indicated: These

patients may need a home health agency referral, simple DME, community resource information and/ or referral. Outpatient rehabilitation, outpatient PHGLFDOIROORZXS,WLVDQWLFLSDWHGWKDWWKHSDWLHQW ZLOOKDYHRQO\VKRUWWHUPPHGLFDOQHHGV*HQHUDOO\ VSHDNLQJWKH\KDYHDGHTXDWHLQGHSHQGHQFHDQGRU VRFLDOVXSSRUWVWREHGLVFKDUJHGKRPHZLWKPLQLPDO intervention.

Complex Discharge Planning Indicated:

These patients may need inpatient

rehabilitation, Hospice, Dialysis, medically complex home care, high cost drugs,

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“Nursing Home to Community” Overview

Nursing Home to Community

Referrals

Assessment Process

(20)

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Care Plan Development

Other Community Agencies

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Roles in Discharge/Transition Planning

What is the Role of the Resident?

What is the Role of the Skilled Nursing Facility?

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What is the Role of CASA?

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What is the Role of STIC?

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Procedures of Key Partners

Resident Procedures

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Skilled Nursing Facility (SNF) Procedures

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1. Referral and Initial Contact:

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People with Disabilities with Complex Discharge Care Plans:$WWLPHVWKHUHVLGHQW¶V RU IDPLO\¶V FRQ¿GHQFHLQKLVKHUDELOLW\WROLYHLQWKHFRPPXQLW\FRPHVLQWRTXHVWLRQ)RUWKLV UHDVRQLW¶VLPSRUWDQWWKDWJRDOVDUHHVWDEOLVKHGFOHDUO\DQGWKDWVNLOOHGQXUVLQJIDFLOLW\VWDII DQGFRPPXQLW\DJHQFLHVZRUNWRJHWKHUZLWKWKHUHVLGHQWWREXLOGFRQ¿GHQFHDQGDFWLYHO\ HQJDJHWKHUHVLGHQWLQDFFHVVLQJVHUYLFHV,WKDVEHHQ&$6$¶VH[SHULHQFHWKDWWDNLQJWKHWLPHWR GHYHORSDJRRGFDUHSODQLVZHOOZRUWKWKHHIIRUWUDWKHUWKDQUXVKLQJWRGLVFKDUJH 8SRQUHFHLYLQJDUHIHUUDO&$6$PDNHVDQinitial contactZLWKWKHUHVLGHQWDQGRUIDPLO\PHPEHUV DQGVNLOOHGQXUVLQJIDFLOLW\VWDIIZLWKLQWZR  EXVLQHVVGD\VWRVFKHGXOHDQDVVHVVPHQWYLVLW7KLV YLVLWXVXDOO\WDNHVSODFHZLWKLQ¿YH  EXVLQHVVGD\VRUEHIRUHGLVFKDUJHGDWH

2. Discharge/Transition Planning:

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STIC Procedures

1. Referral and Initial Contact:

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2. Transition Planning:

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3. Post Discharge Follow-Up:

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3. Post-Discharge Follow-Up Support:

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Conducting a Discharge Care Planning Meeting:

(31)

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Community Agency Referral Sources

How Can Other Community Agencies Be of Assistance?

Senior

Resource

Line

778-2411

Action for Older Persons

722-1251

Broome

County

CASA

778-2420

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Community Agency Referral Sources

(33)

  6HOI5HIHUUDOV

The Broome County Elder Services GuideSURYLGHVDFRPSUHKHQVLYHOLVWLQJRIVHUYLFHVDYDLODEOH VSHFL¿FWR%URRPH&RXQW\ ,QIRUPDWLRQFDQEHORRNHGXSXVLQJD1HHGV,QGH[DWWKHEHJLQQLQJWKH*XLGHRUDQ,QGH[ DQG7HOHSKRQH'LUHFWRU\DWWKHHQGRIWKH*XLGH 3URYLGHUVPD\REWDLQFRSLHVRIWKH*XLGHIRUXVHZLWKUHVLGHQWVE\UHTXHVWLQJFRPSOHWLQJ DQGUHWXUQLQJWR$23DQ(OGHU6HUYLFHV*XLGH5HTXHVW)RUP 5HVLGHQWVPD\REWDLQVLQJOHFRSLHVRIWKH*XLGHE\SLFNLQJRQHXSDW$23%URRPH&RXQW\ 2I¿FHIRU$JLQJRUDQ\ORFDOVHQLRUFRPPXQLW\FHQWHU 7KHRQOLQH*XLGHPD\EHYLVLWHGDWZZZEURRPHHOGHUVHUYLFHVRUJ Ɣ h h h h

Community Agency Websites:

Action for Older Persons, Inc. www.tier.net/aop

CASA

www.gobroomecounty.com/departments/casa.php

Elder Services Guide Online

www.broomeelderservices.org

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31

Long-Term Care Payment Options

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When will Medicare cover skilled care?

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33

How long does Medicare cover care in a skilled nursing facility?

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residents or persons living in certain types of long-term care facilities?

(38)

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How can a nursing home resident returning to the community get more

information on his/her options for enrolling/disenrolling in Medicare drug

plans?

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(39)

35 7KHUHDUHWZRW\SHVRI0HGLFDLGFRYHUDJH

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Medicaid Buy-In Program

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(40)
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37

What is the role of CASA hospital liaisons in Nursing Home to Community?

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Do any of the partners assess the residents’ home environment in the community prior to discharge?

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Do any of the partners see the resident after they return home?

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If the transition plan fails, will the skilled nursing facility readmit the person?

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To which community agency should the skilled nursing facility make initial referrals? $OOUHIHUUDOVIRULQLWLDODVVHVVPHQWVKRXOGEHUHIHUUHGWR%URRPH&RXQW\&$6$E\FRQWDFWLQJ\RXU OLDLVRQRUFDOOLQJ

(42)

38 What is a level of care assessment?

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What does an assessment consist of?

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What is a care plan/assessment form?

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Who is in charge of securing discharge plans?

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Who develops the home care plan?

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What does Medicare pay for post discharge?

(43)

 What does Medicaid pay for post discharge?

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What is a Medicaid waiver?

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What is CASA’s role in Medicaid waiver programs?

(44)



Does CASA assist consumers going into a skilled nursing facility?

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Is there any agency we can refer to when a resident decides to leave against medical advice?

(45)

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References

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