Transcript Slide 1

Settings of Care Board Game
Answers
Case #1
• Best – Skilled Nursing Facility (SNF)
Goal is to get patient eventually to the highest level of
independence that is reasonable. Nothing in the history to suggest
that she couldn’t live independently (home) again, but since she
lives alone, she is not ready to do that yet. Still having pain, unsafe
to go home alone already noted, she still needs PT (but is working
with PT). SNF will provide time to improve with rehab therapies,
patient qualifies for it (at least 3 days in hospital, needs daily
therapies, is progressing with therapies), cost is reasonable
(Medicare reimbursement, fully for first 20 days, 80% for days 21100).
• Other – Home with home health (PT/OT) + a lot of help from
friends, family willing to come for awhile to help, or other
caregivers
Case #2
•
Best: Assisted Living Facility /Personal Care Home
Patient has two major issues – his cognitive deficits and the new requirement for
insulin injections with accuchecks (with or without sliding scale insulin protocol).
The cognition problems are not new and unlikely to improve (may be progressive)
and the need for insulin is not temporary and dosage will need adjustment. The
cognitive deficits are likely to limit his ability to do his insulin therapy correctly
(even if daughter draws up insulin into syringes and these stored in refrigerator,
patient has to remember to give himself the insulin, interpret accuchecks correctly,
to give sliding scale insulin correctly, and to eat regular meals); the cognitive
deficits also may limit his ability to give himself insulin injections (a new task).
Even if no sliding scale insulin regimen is initiated, he will need daily assistance
with his insulin regimen and an accurate measure of accuchecks. He has some
financial resources, which means that paying for the additional cost of being in a
PCH/ALF may be possible. Most PCHs have staff that can give medications,
including insulin, and do some limited monitoring.
•
Other – Home, but would need to find / hire someone to come in daily (on days
when daughter couldn’t come) to do accuchecks.
Case #3
• Best – Long Term Care Hospital
Patient is low income (so can’t afford to pay out of pocket for any
medications), is severely functionally compromised currently (ie, can’t live
by self), and has no family or others to help her. She needs long term
intravenous antibiotics and the antibiotic she needs is extremely costly.
Meets criteria for most SNFs, but unlikely to be accepted due to high cost
of medication. SNF payments are based on set criteria and are capped for
level of care. Medications need to be included in the capped
reimbursement. Because of the high cost of the daptomycin, the
reimbursement paid to the SNF for this patient’s care would not cover the
cost of the medication (and she has no money to pay for the difference).
LTCH reimbursement is based on the patient’s diagnoses (DRG), but is
higher than that for SNF and should cover the cost of the daptomycin. The
patient likely meets criteria for LTCH in that she needs IV antibiotics, some
rehabilitation, and monitoring of her infectious process
• Other – Skilled Nursing Facility - but unlikely to find one that would
accept patient because would lose money due to high cost of medications
Case #4
•
Best – Hospice in NH
Hospice – The family, as the patient’s health care decision maker, has decided to no longer
hospitalize the patient if he were to get pneumonia or another life threatening illness again.
Patient has a severe nonreversible disease which has caused 3 episodes of pneumonia within
3 months. The likelihood of having another such episode within the next 6 months is very
high. Therefore, the patient meets the criteria for hospice benefits and care (likely life
expectancy of less than 6 months). Hospice benefits are paid out of Medicare (or Medicaid, if
no Medicare coverage). Many hospice patients are managed at home, but in this case the
family has said they emotionally can’t do that. This patient could be admitted to a long term
care facility and receive his hospice benefits there. Hospice benefits, however, do not cover
the cost of the long term care facility “room and board”, so that would need to be paid by the
patient/family, by Medicaid if patient has that payor, or by long term care insurance if patient
had bought that coverage. The cost of inpatient hospice facilities usually are covered under
the Medicare benefit, but the average life expectancy for most patients admitted to inpatient
hospice facilities is less than 7 days. This patient may not have his next episode of aspiration
for several months, so many inpatient hospice facilities would not admit the patient at this
point.
•
Other – Inpatient hospice facility
Case #5
• Best – Home with family/caregivers and home health for rehab therapies
Despite some cognitive deficits, patient is making progress in her
rehabilitation. Even at baseline she was not living alone and has multiple
family members at home to assist her with ADLs on a 24/7 basis. She
needs rehabilitation therapies (PT and OT), but can get these at home
through Home Health (patient would qualify as “homebound”).
• Other – SNF would be an acceptable choice if there is an SNF option that
is located within a hospital structure or in a free standing facility.
However, most SNFs are physically located within a long term care facility
structure, even though the SNF is not for long term care. Therefore, the
family and patient’s agreement in regards to “never going to a nursing
home” may make the SNF option untenable if they are not able to accept
that the SNF is not a “nursing home”. Rehabilitation within an SNF is
usually more extensive (5 days a week) than that provided through home
health (usually 2-3 days/week).
Case #6
•
Best - Long term care facility
Patient has progressive cognitive dysfunction with complications (paranoia) that,
when active, affect her ability to do basic functions (such as eat). Although the
complications at the current time can be controlled if she is on psychiatric
medications, if left to her own care, her dementia and psychiatric problems would
likely lead to her becoming noncompliant with her psychiatric medication (leading
to a recurrence of her increased disability). She has no family to assist /assure she
takes her medication or help with other ADLs and IADLs. With limited financial
resources, she would be most appropriate for admission to a long term care facility
(dementia unit) with payment of such care by Medicaid.
•
Other - Home
Patient was functioning at home with few resources just prior to her problem
with paranoia. If her paranoia remains under control, she may be able to return to
home, at least for awhile. This would require, at a minimum, that she be
compliant with her psychiatric medication. This might be facilitated by the use of a
long acting parenteral antipsychotic and referral for home visits from a psychiatric
nurse.
Case #7
• Best – Long Term Care Hospital
Patient has multiple medical problems that still need ongoing care
(PEG tube, diet advancement, extensive physical, occupational, and
speech (swallowing) therapies, wound care with wound vac, etc).
These problems are multiple and complex enough to require daily
evaluation by a physician and would qualify him for LTCH admission.
Depending on how he progresses, he may need discharge from
LTCH to SNF for further rehabilitation prior to going home.
• Other - SNF
Patient has a number of daily skilled care needs, but if everything
were stable and/or improving, a high level care SNF could manage
his rehab therapies (PT, OT, SLP), his PEG tube feedings, and his
wound vac.
Case #8
• Best: Home with Home Health
Patient has been living independently up until her new onset of
congestive heart failure. Her long standing low vision should not
interfere with the at home management of her congestive heart
failure if she gets an appropriate scale (large numbers or voiced).
Home health nursing monitoring of her weight, lungs, and vital
signs can be done initially, and they can also provide CHF
management education. Unless the patient is significantly
physically deconditioned from the hospitalization for her CHF, home
with home health is the best option.
• Other SNF- Since the patient lives alone, if she has physical deconditioning as a result of her CHF or the hospitalization, then SNF
would be an appropriate option.
Case #9
• Best -Assisted Living Facility /Personal Care Home
Patient lives alone, has cognitive problems, and no family in the area to
assist him. He has demonstrated repeatedly his inability to comply with
diet and his medication regimen for congestive heart failure. He has no
major physical function disabilities and some financial resources, so the
medication administration assistance and dietary controls offered by a ALF
would be beneficial. He also might benefit from the available social
interactions and activities in an ALF.
• Other – Home with hired caregivers
If there is a personal preference to remain in the senior independent
living apartment, the patient (or his family) could hire the caregiver
assistance needed to see that his medications are administered correctly,
that he weighs himself daily, and that his access to inappropriate diet is
somewhat limited.