Improving Transitions Between Emergency Departments and Long Term Care

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Dennis Leon Gallagher
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1 Improving Transitions Between Emergency Departments and Long Term Care Mary T. Knapp RN, MSN/GNP, NHA, FAAN The Health Care Improvement Foundation January 21, 2014

2 Purpose of Presentation Provide and overview of the services, reimbursement and regulations associated with the provision of long term care and the relevance for hospital emergency department staff

3 Long Term Care Providers Continuing Care Retirement Communities (CCRC) Personal Care/Assisted Living Nursing Facility/Skilled Nursing Facility/Subacute Care

4 Continuing Care Retirement Communities A CCRC is a three to four level of care retirement community. All properties are situated on one parcel of land and usually on several acres. Most CCRC s are corporations

5 CCRC Levels of Care Residential/Independent Assisted Living Memory Care Skilled Nursing Many of these services are situated within different buildings located on the same property

6 Independent Living Accommodations Studios One Bedroom Two Bedrooms Cottages Villas Small homes

7 CCRC Fees and Charges An entrance fee is charged similar to a new home purchase price. The price is based on the size and location of the unit. A monthly rental fee is charged for one person and a small fee is charged for an additional resident. Entrance Age requirements: Between 55 and 62 years of age.

8 Lifetime care Benevolent Funding CCRC Contracts

9 55+ Independent Living No Lifetime Contract for Care

10 Assisted Living Residences An Assisted Living Residence is any premise in which food, shelter, assisted living services, assistance or supervision and supplemental health care services is provided for a period exceeding 24 hours for four or more adults who are not relatives of the operator, who require assistance or supervision in matters such as dressing, bathing, diet financial management, evacuation from the residence in the event of an emergency or medication prescribed for self-administration. An Assisted Living Residence in Pennsylvania is a significant long-term care alternative to allow individuals to age in place and develop and maintain maximum independence, exercise decision-making and personal choice.

11 Personal Care Assisted Living In 2011, the State of Pennsylvania instituted changes in legislation regarding the usage of the term assisted living in Pennsylvania. Prior to this, many people used the terms interchangeably. There are now distinct differences between the two.

12 Personal Care Homes Defined A Personal Care Home is a premise in which food, shelter, and personal assistance or supervision are provided for a period exceeding 24 hours, for four or more adults who are not relatives of the operator, who do not require the services in or of a licensed long-term care facility, but who do require assistance or supervision in activities of daily living or instrumental activities of daily living

13 The Main Differences: The Three Cs Concept An Assisted Living Residence is specifically designed to allow residents enjoying assisted living in Pennsylvania to age in place, meaning that they will not be relocated to a different longterm care facility when their needs increase. Construction In a Personal Care Home, residents live in bedrooms that may be shared with up to three other people. An Assisted Living Residence room is akin to a studio apartment in the sense that the resident will have a private living space with their own kitchen and bathroom. Care Levels In line with the first difference, Assisted Living Residences offer changing services so that a resident may advance to a nursing home level of care when necessary. When living in a Personal Care Home, a person whose health needs become too great will be transferred to a skilled nursing facility, as a Personal Care Home is prohibited from providing acute medical care.

14 Nursing Facility/Nursing Home Licensed by State Certified in Medicare and or Medicaid under Federal Conditions of Participation

15 Nursing Home Regulations: The Nursing Home Reform Act 1987 (NHRA [OBRA 87]) (PL ) Most federal regulation of Nursing Homes stems from The Nursing Home Reform Act Components of the Act include the following: Nursing homes are certified as a Medicare and/or Medicaid skilled nursing facility by the federal government (Centers for Medicare and Medicaid [CMS]). Conditions of Participation : Spells out the mandates that a nursing home is obliged to meet in order to remain Medicare/Medicaid certified and eligible for reimbursement Specifies that people living in a nursing home are residents not patients. Requires that every facility is to care for its residents in such a manner and in such an environment as will promote maintenance or enhancement of quality of life of each resident and to provide services and activities to attain or maintain, for each resident, the highest, practicable physical, mental and psychological well-being.

16 Nursing Home Characteristics and Services Most Nursing Homes (67%) are for-profit 16,000+ Nursing Homes 1.7 Million Medicare and/or Medicaid certified beds 1.5 million+ people (6%+ of people >65 years old) are in Nursing Homes Average Nursing Home Size: 104 beds

17 Resident Characteristics Most residents are white (86%), female (62%), married (17%) and live alone Age range: 75-84: 30%, >85 y/o: 45%, <65 y/o: 12% Assistance needed with 3-4 ADLs: 95% Incontinent of bladder or bowel: 50% Dementia of some kind: 65% Depressed (at least one clinical symptom): 20% Physical restraint use: 6% (some NHs: 0%) Receiving psychotropic medication: 63% 46% of residents are admitted from acute care

18 Resident Length of Stay 50%+ 2.5 years (mean) 50% days (mean) Short-Term (typically Medicare covered) Long-Term (typically Medicaid covered)

19 Hospitalization of Residents Between 25%-50% of residents are hospitalized during any one year Some residents can be hospitalized as many as 4 times in one year (e.g. with diagnosis of COPD, CHF)

20 Reasons for Hospitalization Reasons for hospitalization include: Physician practice pattern and hospital vacancy rate Resident s Medicare eligibility Nursing Home resources (staffing; IV administration; diagnostic services) Family pressure

21 Staffing in Medicare and Medicaid Skilled Nursing Homes On-site supervision 24/7 by a licensed nurse (RN, LPN); an RN must be on duty 8 hours/day, 7 days/wk. -Nursing: 66%+ of Nursing Home staff (RN, LPN, Certified Nurse Assistant or CNA) Pennsylvania requires 2.7 direct care nursing hours per Resident per day Full-time licensed administrator Therapeutic staff: social worker, activities therapist, nutritionist, and rehab therapy staff (full or part time required) Medical director (at least 20% time) Physician for every resident

22 Special Care Units (SCU) 3000 Nursing Homes (19+%) have designated a Special Care Unit (SCU) Dementia SCUs are the most common type (22%) (Originally for residents with mild/moderate stage dementia) Sub-acute Care Units provide short-term intensive rehab and continuous medical monitoring Types of Sub-acute Care Units include ventilator dependent, traumatic brain injury, oncology, pressure ulcer care, AIDS, skilled rehab, palliative care and hospice units

Oversight and Monitoring of Nursing Homes The following are used in monitoring Nursing Homes: State Departments of Health: Conducts surveys on behalf of CMS CMS 5-Star Quality Rating System Long Term

23 Oversight and Monitoring of Nursing Homes The following are used in monitoring Nursing Homes: State Departments of Health: Conducts surveys on behalf of CMS CMS 5-Star Quality Rating System Long Term Care Ombudsman: State office (federally funded) investigates and resolve complaints regarding resident rights, quality of care (in most but not all nursing homes). Joint Commission: optional except for Nursing Homes seeking managed care contracts or that are hospital-based

24 State Departments of Health Surveys on Behalf of CMS Surveys assess 17 different Categories, including: Resident rights Admission and discharge rights Resident behavior and facility practices Quality of life Resident assessment Quality of care Nursing services Dietary services Infection control Survey assessment of individual residents includes: Use of physical restraints Psychotropic medication Staff training & supervision Staffing Care planning Specific outcomes of care and others

25 CMS 5 Star Quality Rating System The CMS 5 Star Quality Rating System is a nationally recognized standard against which to assess nursing homes. Star rating reflects a Nursing Home s quality status for the past month period. Higher star ratings reflect better quality: 5 Stars: top 10% of nursing homes within the state 2, 3, 4 Stars: middle 70% of nursing homes within the state 1 Star: bottom 20% of nursing homes within the state

26 Sample Nursing Home Rating View the Nursing Home Compare web site

27 Resident Assessment: The Minimum Data Set (MDS) The Minimum Data Set (MDS) is: a functional assessment instrument; required by NHRA [OBRA 87] provided by the interdisciplinary team members according to their specialty. the basis for interdisciplinary assessment, care planning, reimbursement, and quality monitoring.

28 Nursing Home Costs and Reimbursement The mean national cost for a nursing home stay is $ 62,000+/year. A two-bed shared room is $169/day 62%+ of residents are dually Medicare and Medicaid eligible. Medicare is primary payer for residents in a Nursing Home for post-hospital skilled nursing and/or rehab (100 days maximum). Medicaid is primary payer for residents in a Nursing Home for an entire year (or longer). Other residents are private pay, i.e. they pay for Nursing Home care out of pocket.

29 Methods to Improve Transitions Communications Situation Background Assessment Recommendation SBAR

30 Documentation Transfer forms Medication Administration Record Advanced Directives

31 Sources

GUIDE TO SUB-ACUTE AND LONG TERM CARE

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