Transcript Standards - National Health Care for the Homeless Council

FORGING THE PATH FOR MEDICAL
RESPITE CARE IN HEALTH SYSTEM
REFORM
August 16, 2014
Alice Moughamian, RN, CNS, San Francisco Medical Respite Program
Sabrina Edgington, MSSW, National Health Care for the Homeless Council
WHY STANDARDS?
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Improve consistency
Improve quality, health
outcomes, and reduce
costs
Improve opportunities
for research
Improve opportunities
for sustainable federal
funding
A 2014 study conducted by Duke University found an
emergence of “patchwork [medical] respite”
processes in the absence of formal medical respite
programming.
Source:
Biederman, D.J., Gamble, J., Manson, M., Taylor, D. (2014). Assessing the
need for a medical respite: perceptions of service providers and
homeless persons. Journal of Community Health Nursing, 31(3),145-56.
PROCESS TO DATE
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Under Leadership of Medical Respite Providers Network
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Medical Respite Standards Development Task Force
→ Representatives of Nursing, Social Work, Medical, Policy, Legal
and Consumer Viewpoints
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Conducted monthly meetings
→ Began Fall 2011
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Focus on the minimum standards
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Alignment with other standards
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Goal to accommodate a diverse range of providers
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STANDARD 1: ACCOMMODATIONS
MEDICAL RESPITE PROGRAMS PROVIDE SAFE AND
QUALITY ACCOMMODATIONS
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24 hour bed
Hygienic
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→
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Shower facilities
Laundering facilities
Clean linens
Janitorial services
Accessible and
minimal fall risk
Secured storage
STANDARD 1: ACCOMMODATIONS
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Food (3 meals/day)
24 hour staff presence
→ Trained in first aid and basic life support
→ 24-hour on call medical support at non-congregate facilities
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Safety plans
→ Policies and procedures for responding to life-threatening
emergencies (i.e., medical emergencies)
→ Patient understanding of fire and evacuation plans
→ Code of conduct
→ Policy for handling alcohol and illegal or non-medical
prescription drugs
→ Policy for weapons and staff response to violence
STANDARD 2: ENVIRONMENTAL SERVICES
MEDICAL RESPITE PROGRAM PROVIDES QUALITY
ENVIRONMENTAL SERVICES
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Safe handling of biomedical
and pharmaceutical waste
and other biohazardous
materials as needed
Communicable disease
management
Medication storage
Pest Control
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CONSIDERATIONS FOR COMMUNICABLE
DISEASE MANAGEMENT
OTHER CONSIDERATIONS FOR
COMMUNICABLE DISEASE MANAGEMENT
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TB
C. diff
Hep A
→ Fecal – oral route
→ Implications in food service (i.e., Standard 1)
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Impetigo
→ Standard 1 implications
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Shingles
MEDICATION STORAGE
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Licensing
→ Administering vs. Dispensing
→ Meds need to be stored according to manufacturer
requirements
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Special considerations
→ Insulin
→ Controlled medications
→ Oral chemo agents
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Special precautions
→ Outpatient chemo
STANDARD 3: CARE TRANSITIONS TO MEDICAL RESPITE
MEDICAL RESPITE PROGRAM MANAGES TIMELY AND SAFE
CARE TRANSITIONS TO MEDICAL RESPITE FROM ACUTE CARE,
SPECIALTY CARE, AND/OR COMMUNITY SETTINGS
CARE TRANSITIONS:
The movement of patients between health care locations,
providers, or different levels of care within the same location as
their conditions and care needs change. This may include the
transition from the hospital to a primary care provider, home, or
nursing facility.
National Transitions of Care Coalition. (2008). Transitions of care measures.
Retrieved from
www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf
STANDARD 3: CARE TRANSITIONS TO
MEDICAL RESPITE
Improving Care Transitions for People Experiencing Homelessness
http://www.nhchc.org/wp-content/uploads/2012/12/Policy_Brief_Care_Transitions.pdf
STANDARD 3: CARE TRANSITIONS TO
MEDICAL RESPITE
Preadmission
→ Working with hospitals to promote medical respite as a discharge
option
→ Trainings to promote appropriate referrals
→ Timely admission decisions by qualified medical personnel
→ Admission decisions based on ability to keep patients safe and
provide the care, treatment, and services needed by the patient
→ Communication with referring agencies when beds are not
available or a referral is denied
STANDARD 3: CARE TRANSITIONS TO
MEDICAL RESPITE
Admission
→ Designated point of contact for referring entities
→ Transportation responsibilities from referring entity to medical
respite is outlined in written agreements
→ Protocols for transferring patient information
→ Medication reconciliation
→ Reinforcement of discharge instructions
→ Patient has and knows his/her accountable provider(s) at all
points of care transition
STANDARD 4: CLINICAL CARE
MEDICAL RESPITE PROGRAM ADMINISTERS HIGH
QUALITY POST-ACUTE CLINICAL CARE
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Clinical care provided at the medical respite
program
Ensures an adequate level of care
Requires qualified medical personnel
Patient focused
Interdisciplinary
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QUALITY POST-ACUTE CARE
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Medical records maintained according to
local, state, and federal guidelines
Patients have encounters with clinical staff
based on medical need
→ RN’s on-site, consult provider as needed
→ Provider on-site for referral consultation, admissions,
urgent issues, pain management, medication
changes
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q24 hour wellness checks
Providers follow clinical practice guidelines
QUALITY POST-ACUTE CARE
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Interdisciplinary team
→ Care and treatment discussed on regular basis with all
members
→ All information is shared with team and patient
→ Meets regularly to assess plan and progress towards goals
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Individualized Respite care plan
→ Patient care is delivered in an interdisciplinary and patient
centered manner.
→ Developed in a collaborative manner
→ Care plans are assessed, reassessed and altered
accordingly
STANDARD 5: CARE COORDINATION/SUPPORT SERVICES
MEDICAL RESPITE PROGRAM ASSISTS IN HEALTH CARE
COORDINATION, AND PROVIDES WRAP AROUND SUPPORT
SERVICES.
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Care coordination within the medical respite program
and during the medical respite stay
Medical care coordination
Case Management/Social Services
Coordinate or provide transportation to medical and
social service appointments
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CARE NAVIGATION
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Connection to Community PCP
Connection to Community Specialty Care
Pharmacy reconciliation
Transportation to and from appointments
Connection to community case management
OTHER EXAMPLES
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Respite as an opportunity
Nutrition, rest, recovery
Housing process can begin
Benefits acquisition
Mental Health referrals
Substance use referrals
Medication adherence and teaching
CASE STUDY: MR. H
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54 y/o male with uncontrolled diabetes, s/p
amputation of R 5th toe for osteo and gangrene
Comes to respite for post op recuperation and follow
up.
Exchanging security services for room/board. Now that
he is unable to work, has lost housing.
MR. H: MEDICAL CARE PLAN
Medical Care Coordination
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Wound care
Podiatry and Diabetes follow up
Establish PCP
Blood sugar, diet, glucometer teaching
MR. H: SOCIAL SERVICE PLAN
Social Service Care Coordination
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Erroneously put on SSDI in 2002. Has since been unable to get
ID, job, benefits
Ethics for discharge prior to SSDI being resolved
Discharge Planner (MSW) worked to get birth cert,
fingerprints, hospital records, involved local, state and federal
agencies. Pelosi’s aide got meeting with SSA
MR. H: RESULT
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Although engaged in the medical care plan,
required follow up surgeries, additional amputation
While taking care of medical needs, could use
time to handle social service needs
Ended up as our second longest length of stay ever
(234 days)
Just moved to permanent supportive housing on
Tuesday 
STANDARD 6: CARE TRANSITIONS FROM MEDICAL RESPITE
MEDICAL RESPITE PROGRAM FACILITATES SAFE AND
APPROPRIATE CARE TRANSITIONS FROM MEDICAL RESPITE TO
THE COMMUNITY.
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Discharge planning
→ Begins early
→ Discharge policy & procedure, including who makes discharge
decisions
→ Pt receives at least 24 hours notice prior to discharge from
medical respite (exceptions for administrative discharge)
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Discharge summary to the patient and community
providers assuming patient care
Patient provided with options for placement after
discharge
STANDARD 7: MEDICAL RESPITE CARE IS
DRIVEN BY QUALITY IMPROVEMENT
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Requires competent staff
Systematic and continuous actions that lead to
measurable improvement in Respite outcomes
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STAFFING REQUIREMENTS
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Core competencies for staff
→ Includes volunteers
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Job descriptions and annual performance
appraisals
Medical director required
Appropriate training, certification and licensing is
maintained
Staffing based on program’s ability to provide
clinical care and clinical complexity and acuity.
Incident reporting
DATA MEASUREMENT
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Established and secure data collection process
→ Program specific performance priorities for data collected and
frequency
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Plan to identify and respond to trends, outcomes,
patient experience and performance measures.
Ability to conduct self audits
LCR MED REC #
DPH MEDICAL RESPITE Episode Form
CITY AND COUNTY OF SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH
DPH MEDICAL RESPITE
Episode Form, PAGE 2
CAUTION: Federal and State laws protecting confidential patient information apply to patient information contained in this completed form.
MEDICAL RESPITE CLIENT INFORMATION
FIRST NAME
SSN
DOB
MEDICAL RESPITE LINKAGES
REFERRED BY WHICH HOSPITAL (choose one)
YEAR
 SFGH
 St. Francis
 Kaiser
 CPMC Davies
 VA Hosp
 CPMC Pacific
 St. Mary’s
 CPMC California  St. Luke’s
 Other Hosp (specify):
PRIMARY LANGUAGE
GENDER
ORIENTATION/PREFERENCE
 Caucasian
 African American
 Latino/a
 Filipino/a
 English
 Spanish
 Other:
 Male
 Female
 MTF Transgender
 FTM Transgender
 Other
 Declined to Answer
 Heterosexual
 Gay  Lesbian
 Bisexual  Unsure
 Other
 Declined to Answer
CURRENT LIVING
SITUATION
 Other:
Choose one: Select
situation that applied
prior to client’s
hospitalization.
 Asian
 American Indian /
Alaskan Native
 Native Hawaiian or
Other Pacific Islander
Homeless:
Homeless Transitional:
Permanently Housed:
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(with tenancy rights):
 SRO Non-Supported
 SRO Supported
 Board and Care
 Apartment
 House
Shelter, no CM
Shelter, with CM
Outdoors
Encampment
Abandoned Bldg
Vehicle
Other
 Diagnostics:
 Pharmacy:
_______________________________________  N/A  Already Active  Reconnect  New Connect  Offered/Refused
 ICM Team: _______________________________________  N/A
 Community Nursing Care:
MONTH: ___________
YEAR:
___________
 SA Tx:
 Already Active  Reconnect  New Connect  Offered/Refused
___________________________  N/A  Already Active  Reconnect  New Connect  Offered/Refused
 Already Active  Reconnect  New Connect  Offered/Refused
__________________________________________  N/A  Already Active  Reconnect  New Connect  Offered/Refused
 Specialist:
_____________________________________________  N/A  Already Active  Reconnect  New Connect  Offered/Refused
 Specialist:
_____________________________________________  N/A  Already Active  Reconnect  New Connect  Offered/Refused
 Other:
__________________________________________  N/A  Already Active  Reconnect  New Connect  Offered/Refused
(choose only ONE option from MEDICAL HISTORY below and write here)
 Housing: _______________________________________________  Already Active
REFERRING PRIMARY PURPOSE(S) FOR ADMISSION (choose all that apply):
 ID:
 ARV Initiation  Wound Care  PO Antibiotics  IV Antibiotics  Med Mgmnt  Reconditioning/Rehab
 CM  Anticoagulation  Med Teaching  Chemo/XRT  Awaiting Medical Procedure  Assisting with Follow-up
 Other (specify):
 Unable / Refused to
Answer
Denies History
Ambulatory Disability
Anemia
Assault
Asthma
Autoimmune Disease
CAD
Cancer
Cardiac Arrhythmia
CHF
Chronic Pain
Cirrhosis
Cognitive Disorder NOS
COPD
Dental Condition
Derm Condition
Diabetes
Endocrine
GI Disease
Other (specify):
IDENTIFIED DURING STAY:
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



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REFERRAL MH HISTORY
GYN Disease
Hepatitis C
HIV/AIDS
Hypertension
Neuro disease
Open wounds,
skin and soft
tissue infection
Ortho Condition
Osteomyelitis
Pneumonia
Post-Op Care
Renal Disease
Seizure disorder
TBI
Thromboembolic
Disease
Urologic
Condition
UTI
Vision Disability
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Unable / Refused to Answer
Denies History
None
Adjustment Disorders
Substance Related Diagnoses
Anxiety Disorders
Delirium, Dementia, and
Amnesic and Other Cognitive
Disorders
Disassociative Disorders
Factitious Disorders
Impulse Control Disorders Not
Elsewhere Classified
Mood Disorders
Personality Disorders
Schizophrenia and Other
Psychotic Disorders
Sexual and Gender Identity
Disorder
Sleep Disorders
Somatoform Disorders
Other Conditions (specify):
IDENTIFIED DURING STAY:
Unable / Refused to Answer
Denies History
None
Alcohol
Barbiturates and other sedatives /
hypnotics
 Benzodiazepines and other
tranquilizers
 Cocaine / Crack Cocaine
 Ecstasy & other club drugs
 Hallucinogens / PCP
 Heroin
 Inhalants
 Marijuana / Hashish
 Methamphetamine and other
amphetamines
 Nicotine
 Other Opiate *
 Over-the-counter *
 Unknown drug(s) *
* Specify:
 Already Active  Applied, Award Date:_______________________  Offered/Refused
 Medical Coverage Benefit: Medi-Cal / Medicare / VA:
DID STAY RESULT IN
CHANGE OF LIVING
SITUATION?
 NO  If YES
check new
situation:
 Already Active  Applied, Award Date: __________________  Offered/Refused
Homeless:
Homeless Transitional:
Permanently Housed:
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


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(with tenancy rights):
 SRO Non-Supported
 SRO Supported
 Board and Care
 Apartment
 House
Shelter, no CM
Shelter, with CM
Outdoors
Encampment
Abandoned Bldg
Vehicle
Other
SRO Temporary
Jail/Prison
LTC or Residential Treatment
Temp situation w family/friends
Foster Care
SRO living with child(ren)
COMMENT:
DISCHARGE DISPOSITION
MONTH
DAY
MEDICAL TREATMENT PLAN COMPLETED BEFORE DISCHARGE?
YEAR
 YES  NO, COMMENT:
Discharged to: (review options 1 through 15, select only one)
1.
2.
3.
4.
5.
6.
IDENTIFIED DURING STAY:
 Applied  Offered/Refused
CA ID / SS# Card / Other : _____________________________  Already Active  Applied  Offered/Refused
 Income Benefit: CAAP / SSI / SSDI / VA / Other:
REFERRAL SA HISTORY

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

 Reconnect  New Connect  Offered/Refused
___________________________________________  N/A  Already Active  Reconnect  New Connect  Offered/Refused
 MH Tx: __________________________________________  N/A
LAST TIME CLIENT
WAS PERMANENTLY
HOUSED:
REFERRING PRIMARY DIAGNOSIS AT ADMISSION:
REFERRAL MEDICAL HISTORY
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




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SRO Temporary
Jail/Prison
LTC or Residential Treatment
Temp situation w family/friends
Foster Care
SRO living with child(ren)
 PC Provider: __________________________________________________  Already Active
DC LIVING
SITUATION
ADMIT PURPOSE
ETHNICITY (choose all that apply)
CLIENT INFO
 UCSF
TIME
M.I.
ADMIT LIVING
SITUATION
ADMIT
DATE
ALIASES
DAY
FIRST NAME
DATE:
BRIEF DESCRIPTION OF ADVERSE EVENT
LAST NAME
MONTH
LAST NAME
ADVERSE EVENT
7.
8.
 * Psychiatric Emergency Program/Facility:
 * Medical Emergency Department:


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
 PES
 Westside Crisis  Dore Urgent Care Clinic
5150?  Yes  No
 St. Luke’s
 SFGH
 St. Francis
 CPMC Davies
 CPMC Pacific
 CPMC California
 UCSF
 Kaiser
 VA Hosp
 St. Mary’s
 Other Hospital: ________________________________________



12. 
13. 
14. 
15. 
Medical Detox Program
9.
AWOL
Social Detox Program
10.
Residential Treatment Program: ____________________
11.
* Escorted out due to violent behavior or threat of
* Discharged due to inappropriate behavior
* AMA
* Discharged to Police Custody
* Death
Hospice: ______________________________________
Long Term Care: ________________________________
Completed program and discharged to self-care
Address/hotel/room#, if known:
_________________________________________________
415-255-3706 – Form Revised 051309
Other as follows: ______________________________
(* Requires Adverse Event section to be completed)
 ENTERED INTO CCMS:
DATE: _____________________BY: _______________________
NEXT STEPS
• Anticipated public comment period: 9/1/14-9/30/14
• Revisions based on public comment/Task Force
discussion
• Testing at volunteer sites
• Revisions based on testing
• Final standards issued
NEXT STEPS
• Used for training and technical assistance
• Opportunities for accreditation/certification
• Opportunities for research related to health
outcomes/quality of care/costs
• Engage in discussions at federal level to promote
sustainable funding
Q&A
Alice Moughamian, RN, CNS, Nurse Manager
San Francisco Medical Respite Program
[email protected]
Sabrina Edgington, MSSW, Director of Special Projects
National Health Care for the Homeless Council
[email protected]