WHAT DO WE DO WITH THIS PATIENT?DISCHARGE PLANS

Susan T. Bray-Hall, MD

THE AMERICAN GERIATRICS SOCIETYGeriatrics Health Professionals.

Leading change. Improving care for older adults.

AGS

Hospital:

A-fib, Stroke

Hospital:

MI, CHF

Hospital:

CHF6 days 4 days 8 days

18 days in hospital, 35 days in NH

…… 312 days at home

ONE YEAR OF CHRONIC ILLNESS

Nursinghome stay

35 days

Home health episodes45 days

28 days62 days

Courtesy Peter Boling, MD Slide 2

BACKGROUND: MEDICARE

• Part A Hospital, hospice, home care, skilled nursing

facility, equipment

• Part B Outpatient care, MD services (80% coverage)

• Part D Pharmacy benefit

Slide 3

BACKGROUND: MEDICAID• State-specific

• Income limit $600$1800/month

• Asset limit $2000

• Covers co-pays, home care, equipment, transportation

Slide 4

DISCHARGE OPTIONS

• Acute inpatient rehabilitation

• Skilled nursing facility (SNF) / Transitional care unit (TCU)

• Home with skilled home health care

• Nursing home

• Hospice

Slide 5

ACUTE INPATIENT REHABILITATION

Slide 6

• Patient can tolerate 3 hours of rehabilitation daily

• Post-stroke, postjoint replacement, post-amputation, brain or spinal cord injury

• NOT general decline from medical illness

ACUTE INPATIENT REHABILITATION:WHO PAYS?

• Medicare ADays 120: 100%Days 21100: 80%

• Remainder from private pay, private insurance, Medicaid

• Approximate cost $600/day

Slide 7

SNF/TCU

• Patient needs post-hospital rehabilitation

• Patient requires 3-night hospital stay (within 30 days)

• Nursing, physical therapy, occupational therapy, speech therapy

• Patient is required to make continued progress

Slide 8

SNF/TCU: WHO PAYS?

• Medicare A Days 120: 100% Days 21100: 80%

• Co-pay: private pay, private insurance, Medicaid

• Approximate cost $350$600/day

Slide 9

HOME WITHSKILLED HOME HEALTH CARE

• Primary caregivers: Nursing (wound, med adjustment, disease monitoring) Physical therapy Speech therapy

• Secondary caregivers: OT, MSW, RD, CNA

Slide 10

SKILLED HOME CARE: WHO PAYS?

• Medicare A Pays for non-physician services No limit on length of care but paid on DRG Patient must be homebound

• Medicare B pays 80% of physician visits

Slide 11

UNSKILLED HOME CARE:WHO PAYS?

• Private pay

• Medicaid: up to 40 hours/week of Home and Community Based Services (HCBS)

Slide 12

NURSING HOME

• Custodial care only

• Patient would have no benefit from skilled rehabilitation

Slide 13

NURSING HOME: WHO PAYS?

• Medicaid or private pay

• $50,000$80,000/year

• $150/day (Medicaid rate)

Slide 14

HOSPICE

• “Would I be surprised if this patient died within the next 6 months?”

• Patient needs one hospice diagnosis

Slide 15

HOSPICE: WHO PAYS?

• Medicare A Pays for hospice team and medications Does not pay for room and board

Slide 16

SUCCESSFUL TRANSITIONS (1 of 3)

• Discharge planning Patient activation Medication reconciliation Red flags Follow-up

• Discharge summary Does not need chronology Needs outcomes! Timeliness!

Slide 17

SUCCESSFUL TRANSITIONS (2 of 3)

• Medication reconciliation Focus on medication changes

• Pink sheet/Transfer orders Full medication list Labs needed Follow-up plans Services requested; wound care orders, etc.

Slide 18

SUCCESSFUL TRANSITIONS (3 of 3)

• Think of transitions as a medical procedure Improve patient safety Improve patient care Improve patient satisfaction

Slide 19

It is AS importantwhere and how you discharge the patient as the procedures

and treatments you didin the hospital

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