FUNCTIONAL ASSESSMENT AND DETERMINATION OF LEVELS OF CAREIN OUR GERIATRIC PATIENTS

Vinh Nguyen, MD, MBAAssistant Clinical ProfessorDivision of Geriatric Medicine and GerontologyDepartment of Family MedicineUniversity of California, Irvine

OBJECTIVES Functional tools for assessing the older adult. Using tools to work on your plan of care. Understand physical performance tests pertinent

to the older adult. Know different levels of care available. Understand some basics of CMS coverage for

resources. Use knowledge of levels of care to optimize your

patient outcomes. Plan ahead for patient disposition planning.

ADL AND IADL Activities of Daily

Living Feeding Grooming Continence Toileting Ambulation Dressing Bathing

Instrumental Activities of Daily Living Telephone Cooking Housework Laundry Transportation Shopping Medications Finances

KATZ AND LAWTON SCALES

Image from: http://consultgerirn.org/uploads/File/trythis/try_this_23.pdf

SOCIAL HISTORY Not just T/E/D Gather a thorough social history

Family Caregiver assistance Caregiving for others Home setting

Apartment/Condo/Home Number of stories Steps in or out

Safety at home Language and culture Education Profession or prior work

PHYSICAL PERFORMANCE TESTING Gait

Get up and go test 10 feet Time?

Gait speed >0.8-0.9 m/s: community independence >0.6m/s: community ambulation sans WC

Tinetti Balance and Gait Grip strength

LEVELS OF CARE Post hospitalization AKA “Disposition” Multi-disciplinary approach

Physical/Occupational/Speech Therapy Social work Patient’s wishes Family and friends

Planning, planning, planning…

POST ACUTE CAREType Description Payor Basis for

Medicare Payment

Cost Range $ per day

Physician Type

Acute Inpatient Rehab

3 hours of PT/OT per day. High intensity rehabilitation.

Medicare Part AMedicaid

Payment per episode of care based on complexity

1000-2000 PM&R

Skilled Nursing Facility

Skilled needs can include variety of things including medications, wound care, rehab, etc.

Medicare Part AMedicaid

Daily rate, first 20 days paid by Medicare then day 21 to 100 80% is paid and 20% by patient.

150-300 PCP

Long-term acute care hospital

Medicare facility for handling complex patients such as ventilator care/weaning, critical care patients needing more frequent physician followup

Medicare Part A Medicare Diagnosis Related Group

1500-3000 Hospitalist

Home health care Medicare certified care run by nurses as well as PT/OT/ST/SW

Medicare Part A (DME on Part B)

Payment per episode of care based on complexity

100-300 PCP

Outpatient Rehab Medicare Part BMedicaid

Pay per visit 100-200 PCP

Hospice and Palliative Care

Terminal illness with focus on nonhospital care and symptom management AND active support like hospicebut without expectation of avoiding further medical care.

Medicare Part AMedicare Part B

Payment per day 200-300 PCP or palliative care specialist

Adapted from JAMA, 01/19/2011-Vol305, No.3 “Finding the Right Level of Posthospital Care”, Robert L. Kane, MD.

LONG TERM CAREType Description Payor Basis for

Medicare Payment

Cost Range $ per day

Physician Type

Home care/Personal care

Services for frail persons needing help with ADL or IADLs

Medicaid. Ex. IHSS Per hour payment 75-150 PCP

Nursing Home Certified for long term care. Special units?

Medicaid Payment per day 75-300 PCP

Assisted living Institutional care with apartment like living quarters and some assistance on a “a la carte” basis.

Medicaid (in some states with vouchers)

Payment per day/month

60-300 PCP

Day care or adult day health centers

Community faciltiies for centralized care for various periods of the day.

Medicaid (some states)

Payment per use 60-120 PCP

Adult foster care Small group homes with care by nonprofesionals

Medicaid (some states)

Payment per month 50-100 PCP

Independent living Room and board and some housekeeping. Community activities and amenities like meals.

None 50-100 PCP

Board and care Varient of independent living, with room and some meals

None PCPAdapted from JAMA, 01/19/2011-Vol305, No.3 “Finding the Right Level of Posthospital Care”, Robert L. Kane, MD.

HOW DO YOU CHOOSE?!? Current and prior level of function Therapy needs Psychiatric care needs Expectations Finances Social support Resources such as Center for

Medicare/Medicaid Services and Veterans Affairs. Also state and county resources.

CASE QUESTIONS