October 30, 2012

2

Reduce preventable hospital readmissions Safe transition from SNF to home Provide lower cost, high quality alternative

to acute care setting Provide patient-centered care

3

Part A (Hospital Insurance) Qualifying Hospital Stay – Inpatient hospital

stay of 3 consecutive midnights Doctors orders for skilled services Skilled care required daily Up to100 day episode of care

4

Required for traditional Medicare Fee For Service under Part A

Exceptions:◦ Medicare Advantage (Part C)

Tufts, Fallon, Blue Cross Blue Shield, etc.◦ PACE-Program of All Inclusive Care for the Elderly◦ SCO (Dual Eligible)-Senior Care Options◦ MGH Waiver Program

5

UTI Dehydration Pneumonia COPD CHF Diabetes Hypertension

6

Part A (Hospital Insurance) Services provided under a plan of care

established & reviewed regularly by a physician

Require one or more of the following◦ Skilled nursing care less than 7 days/week◦ PT, OT or ST

Certified homebound by physician Up to 60 day episode of care; 30 day

window

7

24 – hour-a-day care at home Meals delivered to home Homemaker Services Personal Care (bathing, dressing and using

the bathroom) when this is the only required care

8

Communicate with Skilled Nursing Facility and PCP

Provides Consistent Care Givers Telemedicine – Early symptoms recognition

and monitoring

9

Mismanagement of medications Moderate to severe functional impairment Inadequate patient/family education Lack of family safety net Comorbidities Patient reluctant to allow care givers in

home Failure to keep follow up appointments Poor diet, insulin management Substance abuse

10

Discharge planning starts on admit date Communication with patient, family, PCP

and home health agency Care management meetings with patient,

nursing, therapy and case management Discharge meeting with home health care Family and Patient education PCP notification – medication, lab, pending

tests and any special needs Electronic medical records

11

C.O.A.C. H.◦ Communicate Expectations◦ Organize goals◦ Assign coach◦ Continued review◦ Handoff homework

12

Home Health Care Agency (HHCA) Case Manager◦ Reviews patient chart w/SNF Interdisciplinary

Team (IDT)◦ Attends Discharge Planning Meeting at SNF◦ Coordinates required services (Nursing, Therapy,

etc.) with IDTSNF Case Manager◦ Schedules Home evaluation◦ Orders DME◦ Provides education to family care givers

13

Conducts follow up calls with patient/family (within 48 hours)◦ Seek feedback-How patient is succeeding at home◦ Follow up on patient concerns◦ Provide over the phone education◦ Assist in providing additional/services if needed◦ Readmit to facility within 30 days (3 day inpatient

hospitalization not required)

14

Include home health care providers in the discharge process

Educate home health care work force on SNF rules of participation, clinical capabilities, positive patient outcomes

Create an image; the SNF is part of the continuum

Common names; Rehab, Short Stay, Post Acute, Transitional Care

Section 87 State Health Care Reform Law

15

Coordinate readmission process between home health nurses and SNF

Track & trend outcome data and communicate results with stakeholders

Expand Circle Events to include direct admits from physician offices and emergency rooms when appropriate

Proposed State waiver of qualifying hospital stay

16