Transcript Presentation - Massachusetts Coalition for the Prevention of Medical

October 30, 2012
(Percentage)
(Dollars in Billions)
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Inpatient Hospital
39
Physician Services
29
Outpatient
14
Skilled Nursing Facility 8
Home Health Agency
6
Hospice
4
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Total 2010 Medicare Expenditures:331 Billion
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130
96
46
26
20
13
2
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Reduce preventable hospital readmissions
Safe transition from SNF to home
Provide lower cost, high quality alternative to
acute care setting
Provide patient-centered care
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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
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Required for traditional Medicare Fee For
Service under Part A
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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
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UTI
Dehydration
Pneumonia
COPD
CHF
Diabetes
Hypertension
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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
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Certified homebound by physician
Up to 60 day episode of care; 30 day window
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Services provided under a plan of care
established and reviewed regularly by a
doctor
Require one or more of the following
Intermittent skilled nursing care PT, OT, or
Speech
Certified homebound by doctor
Up to 60 day episode of care
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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
9
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Communicate with Skilled Nursing Facility
and PCP
Provides Consistent Care Givers
Telemedicine – Early symptoms recognition
and monitoring
10
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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
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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
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C.O.A.C. H.
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Communicate Expectations
Organize goals
Assign coach
Continued review
Handoff homework
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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 IDT
SNF Case Manager
◦ Schedules Home evaluation
◦ Orders DME
◦ Provides education to family care givers
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Conducts follow up calls with
patient/family (within 48 hours)
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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)
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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
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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
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