Discharge Planning Heidi White, MD Associate Professor of Medicine Yvonne Spurney, RN Associate Chief Nurse Cristina C. Hendrix, DNS, GNP-BC Associate Professor of Nursing Objectives Describe challenges of care transitions and consequences of poor transitions. Describe role of physicians and other providers in optimizing care transitions Outline the financing of post-hospital care Describe the major discharge options for older adults and what services are provided, including unique resources in the Durham Community Where are they Going? Home Care 1
Discharge Planning Process All team members should participate Begin early Documentation Post-hospital site and care appropriate and ready Physician needs to lead Resources Transitional Care Ensures coordination and continuity of care Care plan and availability of information about the patient's goals, preferences, and clinical status. Includes: Logistical arrangements Education of the patient and family Coordination among the health professionals involved in the transition Coleman EA, Boult C. J Am Geriatr Soc 2003;51:556-7. System level Transitional care challenges Provider level Patient level Home Care 2
Why should we care about poor transitions? Medication discrepancies 14-30% of patients discharged from hospital to home experienced 1 medication discrepancies; 30 d rehospitalization rate among patients with identified discrepancies (14.3%) higher than patients without (6.1%) (P=0.04) a In 86% of NH transfers, at least one medication order was altered (mean 1.4); 20% of changes resulted in an adverse event b a Coleman et al. Arch Intern Med 2005; 165:1842-47; Kwan Y et al. Arch Intern Med 2007;167:1034-40 b Boockvar KS, Fishman E, Kyriacou CK et al. Arch Intern Med 2004;164:545-50. Why should we care about poor transitions? Medication discrepancies 14-30% of patients discharged from hospital to home experienced 1 medication discrepancies; 30 d rehospitalization rate among patients with identified discrepancies (14.3%) higher than patients without (6.1%) (P=0.04) a In 86% of NH transfers, at least one medication order was altered (mean 1.4); 20% of changes resulted in an adverse event b a Coleman et al. Arch Intern Med 2005; 165:1842-47; Kwan Y et al. Arch Intern Med 2007;167:1034-40 b Boockvar KS, Fishman E, Kyriacou CK et al. Arch Intern Med 2004;164:545-50. Inadequate follow-up care post-hospitalization Total Completed Workup Type No. (%) Yes No Diagnostic procedure 115 (47.9) 50.4 49.6 Subspecialty referral 85 (35.4) 72.6 27.4 Laboratory test 40 (16.7) 85.0 15.0 Total 240 (100) 64.1 35.9 Workup Type is the outpatient workup recommended upon discharge from the hospital. Completed indicates whether the recommended workup was done within 6 months after discharge. 240 workups recommended in 191 discharges. Moore C et al. Arch Intern Med 2007. Home Care 3
Hospital to PCP transfer Direct communication between hospital physicians and primary care physicians occurred infrequently Discharge summary Availability at first postdischarge visit low (12%-34%) Remained poor at 4 weeks (51%-77%) Affected quality of care in ~25% of follow-up visits Often lacked important information (e.g., lab results, discharge medications, treatment, follow-up plan) Kripalani S, et al. JAMA 2007;297:831-41. In summary, ineffective transitions lead to Wrong treatment Delay in diagnosis Severe adverse events Patient complaints Increased healthcare costs Australian Council for Safety and Quality in Health Care. Clinical hand-over and Patient Safety literature Review Report. March 2005. Available www.safetyandquality.org/internet/safety/publishing.nsf/content/ AA1369AD4AC5FC2ACA2571BF0081CD95/$File/clinhovrlitrev.pdf HOW DO WE SUPPORT CARE TRANSITIONS? Home Care 4
Durable Medical Equipment needed? Covered by Medicare (mostly) Specific Requirements Courtesy of Jeremy Boal, MD What Non Durable Equipment is needed? Adult Incontinence Supplies Booties Gloves Wound care supplies (covered by Medicare if CHHA involvedsupplied by CHHA as well) Not covered by Medicare Usually covered by Medicaid What nutrition will be available For my patient? Home Care 5
How will my patient obtain, understand, and manage medication? What obstacles await my patient at home? Discharge Planning Process Ideally, all team members should participate begin early MD should provide D/C summary and orders, including med reconciliation Site of care after D/C should be warranted by Patient s needs and abilities Physician needs to lead Resources Home Care 6
Who Pays? Payment System Medicare (Title XVIII) 65 years and older qualify Part A: hospital care, home health services or skilled nursing care, and hospice Part B: physician visits, durable medical equipment Monthly fee Part C Part D Medicaid (Title XIX) Medical assistance for people with limited resources Level of state participation varies All states must pay for nursing home care What Does Medicaid Cover? Doctor Bills Hospital Bills Prescriptions (Excluding prescriptions for Medicare beneficiaries) Vision Care Dental Care Medicare Premiums Nursing Home Care Personal Care Services (PCS), Medical Equipment, and Other Home Health Services In-home care under the Community Alternatives Program (CAP) Mental Health Care Home Care 7
Sites of Post Hospital Care Site Requirements Funding Inpatient rehab Pt can tolerate 3 hours of rehab/d requiring multiple disciplines (e.g. PT/OT/ST) Medicare Part A pays 100% for days 1-20 copay for days 21-100 with Part A covering the rest pt pays 100% after day 100 Select Specialty Hospital - Durham 24-hour Respiratory Therapists ACLS Certified Nursing Care Case Management and Discharge Planning Clinical Pharmacy Services Daily Physician Visits Vent Weaning Beriatric Care Sites of Post Hospital Care Site Requirements Funding Long-term Acute Care (LTAC) Complex med needs. Hosp level but not that sick; too sick for SNF ~20-30 days e.g. vent wean; IV Abs Medicare Medicaid Some commercial Home Care 8
Sites of Post Hospital Care Site Requirements Funding Skilled Nursing Facility (SNF) Pt requires skilled nursing care can t tolerate 3 h of therapy/d 2 skilled needs 3 hospital overnights Medicare Part A 100% of charges for days 1-20 copay ($141.50 in 2011) days 21-100 pt pays 100% after day 100 Post Hospital Care in the Nursing Homes Response to reduced length of stay in acute care Integrates features of acute care/rehab focused Interdisciplinary staffing Nursing: RN, LPN, CNA, wound care Therapies: PT/OT/ST, nutrition, SW, etc Medical: MD, PAs, NPs Other clinical: dental, podiatry, vision, psych, psychology, clinical pharmacist Ancillary Services in the Nursing Home Phlebotomy/Laboratory Radiology EKG IVs: peripheral, PICC, etc Echocardiography/Holter monitors No Dobhoffs or Central Lines Can have PEGs Everything happens more slowly Home Care 9
Interface of Acute and Long term Care Most nursing-home residents are admitted from an acute-care hospital Suboptimal information transfer is common Summaries, meds omitted/changed, advance directives, psychosocial issues High Readmission Rates CMS research found that approximately 45% of hospital admissions among those receiving either Medicare skilled nursing facility services or Medicaid nursing facility services could have been avoided, accounting for 314,000 potentially avoidable hospitalizations and $2.6 billion in Medicare expenditures in 2005. Sites of Post Hospital Care Site Home Health Requirements Funding MD orders must certify that patient is homebound intermittent RN, PT, ST Medicare Part A pays 100% for most professional services (e.g. PT/OT/ST) and HHA Home Care 10
Candidates for Home Health: Care of a pressure or venous stasis ulcer Physical therapy for a hip fracture PT and Occupational therapy after a stroke Family and patient education regarding diabetic monitoring and management Monitoring of vital signs and other clinical parameters in a patient with a CHF exacerbation Home safety evaluation Courtesy of Jeremy Boal, MD Once skilled service has been established other services may also be available: Social work Home health aide services Occupational therapy (can stay open) Nutrition Sites of Post Hospital Care Site Requirements Funding Hospice (home or facilitybased) MD must certify that life expectancy is < 6 months Medicare A pays for most professional svcs and meds related to terminal illness; MD services under Part B Home Care 11
What Medicare Doesn t Pay For Home Health Aide Medicare funded Short duration Pt. must have concurrent acute skilled care A few hours per day Full range of ADLs From Certified Home Health Agency (CHHA); VN supervision PC Homemaker Chronic duration No need for concurrent acute skilled care IADLs & light ADLs Authorized by Area Agency on Aging (AAA) Funding from Agency on Aging Housing Alternatives for Older Adults Home Senior Housing Continuing Care Retirement Communities (CCRCs) Assisted Living Facilities (ALFs) Residential Care Facilities, Board and Cares, Rest Homes Nursing Homes Home Care 12
Where did our patient go? A) Skilled Nursing Facility (SNF)/Subacute Rehab- Nursing Home B) Acute Rehab--Inpatient Rehab C) LTAC D) Long Term Care E) Home with home health F) Hospice Was that the right disposition? Information Government web sites www.medicare.gov/nhcompare/home.asp Triangle J Area Agency on Aging http://www.tjaaa.org/ BenefitsCheckUp https://www.benefitscheckup.org/ Community specific Senior PharmAssist http://www.seniorpharmassist.org/ Other web sites (eg OAA, AARP, Commonwealth Foundation) Home Care: www.aahcp.org Home Care 13