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Discharge Planning and Transitions of Care: Where are they going and why?. Opening the Black Box. Exercise. - PowerPoint PPT Presentation
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UMMS CRIT Module III: Discharge Planning and Transitions of Care
Catherine DuBeau, MDChief of GeriatricsUniversity of Massachusetts
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Discharge Planning and Transitions of Care:Where are they going and why?
Opening the Black Box
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• You admit an 80 yr old woman in transfer from a outside facility. There is no hospital summary, only loose papers and a cover sheet listing hospital admission date and meds (unclear if admission or transfer meds). Her family is unavailable.
• She is delirious, hypertensive, and severely impacted• The last labs sent with her are from 3 days old; Hgb was 7.8
and creat 2.2.• You call the hospital and the floor RN says the pt was
discharged on the previous shift and she knows nothing about the patient.
Exercise
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• You admit an 80 yr old woman in transfer from a outside facility. There is no hospital summary, only loose papers and a cover sheet listing hospital admission date and meds (unclear if admission or transfer meds). Her family is unavailable.
• She is delirious, hypertensive, and severely impacted• The last labs sent with her are from 3 days old; Hgb was 7.8
and creat 2.2.• You call the hospital and the floor RN says the pt was
discharged on the previous shift and she knows nothing about the patient.
Exercise
This is a routine skilled nursing facility admission
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Birth Marriage Age 50 Retirement Death
Episodes of Serious Illness
A Life
Courtesy Peter Boling, MD
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Hospital:A-fib, Stroke
Hospital:MI, CHF
Hospital:CHF
6 days 4 days 8 days
18 days in hospital, 35 days in NH, 135 days of homecare, 312 days at home
Scope of the Problem:Hospital Admission = First of Multiple care transitions
NursingHome Stay
35
Home Health Episodes
45
28 62
Courtesy Peter Boling, MD
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
AHRQ HCUPnet http://www.ahrq.gov/data/hcup/factbk1/10shel.htm
Discharge from Hospital to Other Institutions increases with Age
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• All team members should participate − begin early in hospital course
• Site of care after D/C should be warranted by patient’s needs• MD: Assess medical care needs, provide D/C summary and
orders, do med reconciliation
Discharge Planning
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• All team members should participate − begin early in hospital course
• Site of care after D/C should be warranted by patient’s needs• MD: Assess medical care needs, provide D/C summary and
orders, do med reconciliation
Transition Planning
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Home• Home with services• Inpatient Rehab• Chronic Care Hospital• Skilled Nursing Facility (SNF)• Hospice
Where can patients go after hospitalization?
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Who Pays For What?
Medicaid• to qualify, income and
assets must be below state eligibility levels
• $880/$2,000 indiv, $1090/$3,000 couple
• $8,000 set aside in burial contract
Medicare• Age > 65• Part A – hospital, SNF,
hospice; no premium• Part B – MD visits,
outpatient expenses, home health care; pay premium
• Part D – medications
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• House, apartment; alone, with spouse and/or other family• Senior Housing• Continuing Care Retirement Community (CCRCs)• Assisted Living Facilities, Residential Care Facilities, Board and
Care• Nursing Home
Many possible options for “Home”
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
The provision of diagnostic, therapeutic or support services to the patient in the home for the purpose of restoring and maintaining his or her maximal level of comfort, function, and health.
Home Care
AMA Council on Scientific Affairs, JAMA 1990; 263 1241-1244
Levine SA et al. JAMA 2003; 290:1203-1207.
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Medicare Services in Home Care
• Part A (hospital)– Visiting nurse– HHA– SW– Mental Heath– Dietician– OT/PT/ST
• Part B (20% co-pay)– MD Home Visit– Durable medical
equipment– Diagnostics
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• A physician can refer any patient with an acute skilled need to a home care agency
• Nursing care– Monitoring of vital signs, cor/pulm status– Wound care– DM monitoring and education– Medication management
• PT and OT• Speech therapy
Medicare: “Skilled” Home Care via Certified Home Health Agency
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Durable Medical Equipment
• Covered by Medicare (mostly)• Specific Requirements
Courtesy of Jeremy Boal, MD
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Non Durable Equipment
• Adult Incontinence Pads • Chux• Booties• Gloves• Wound care supplies• Not covered by Medicare• May be covered by Medicaid
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Homemaker• All bathroom equipment• Transportation• Personal or supportive long-term care
What Medicare Doesn’t Pay For
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Medicare pays if 3 day/night in hospital and 24 hr skilled nursing care needed– Duration of coverage depends on types and number of skilled
needs• Integrates features of acute care/rehab• 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
Skilled Nursing and Rehab in Nursing Homes
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Phlebotomy/Laboratory• Radiology• EKG• Venous dopplers• IVs: peripheral, PICC, etc• No Dobhoffs or Central Lines
Ancillary Services
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Needs and can tolerate intensive PT/OT (3 hrs/day)• Medically unstable for SNF
– Needs frequent MD evaluation (> q1-2 wk)– Rising Cr, dropping Hgb– Meds will need adjustment in < 24-48 hr (eg, BP meds,
diuretics)– Needs telemetry, daily/STAT labs
Acute Inpatient Rehab
UMMS CRIT 2010 Module III: Discharge Planning and Transitions of Care
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
• Medical needs– Summary of admitting problems and course– Active Problem list– Recent and important pending labs – Reconciled Medication List (incl admit meds and all changes) and
allergies– Advance directives: DPOA-HC, preferences, goals
• Functional support (ADL, IADL)– Disposition: where from and where next– Functional status: baseline and present– Social support and contact info
• Nursing needs: monitoring, wounds• Rehabilitative needs: PT, OT
4 Core Elements of Transition Information and Communication