Presentation for Hospital Volunteers on Transitional Care Management

ONLINE LANGUAGE COURSES

We at Pathways to Care are here to help guide families facing the difficult choices associated with the care and needs of their aging loved ones. We provide a safe pathway across all

levels of care by having expertise in the following areas...

TRANSITIONAL CARE MANAGEMENTCARE SUPPLIES

LONG TERM CARE CASE MANAGEMENT

HHA

PATIENT

ALF

TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT | GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE | REAL ESTATE SERVICES FOR

SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |


What is Transitional Care Management

Care coordination and counseling services to support the transition from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility (SNF), to the patient’s community setting (home, domiciliary, rest home, or assisted living) in order to prevent re-admissions.

TRANSITIONAL CARE MANAGEMENT | SPECIALIZED INDIVIDUAL COUNSELING | SHORT & LONG TERM CASE MANAGEMENT | GUIDENCE IN LOCATING CAREGIVERS & CARE FACILITIES | SOLUTIONS ON HOW TO PAY FOR CARE |

REAL ESTATE SERVICES FOR SENIORS | MEDI-CAL & VA BENEFITS | TRUST & POWER OF ATTORNEYS |


There Are Two Distinctly Different Types of Acute Hospital Discharge Situations...Both of Which Hold Opportunities For Decreasing Hospital Re-admission Rates

• Discharge from the acute hospital to a skilled nursing facility. Requires safeguarding against a pre-mature discharge from the hospital and better patient care while in the skilled nursing facility. (Kaiser Case Study Example.)

• Discharge from the acute hospital or skilled nursing facility to the home. Requires safeguarding against a pre-mature discharge from the hospital and patient follow-up and 30 day tracking by the primary physician.




How Serious is the Readmissions Problem?

According to the federal government, one in five elderly patients winds up back in the hospital within 30 days of leaving.

The readmission of Medicare patients alone costs $26 billion annually, $17 billion of which is spent on return trips that wouldn’t need to happen if patients received proper care during their first visit and/or had an adequate post discharge follow up.







To Fix The Problem, Medicare is Now Taking Action...

• Penalizing hospitals if the patient returns within 30 days

• in 2015 Medicare will penalize the skilled nursing facilities for patients that readmit to the hospital within 30 days of being discharged from the skilled nursing facility.

• Providing extra Medicare billing revenues for primary physicians who are willing to follow up and track the patient throughout the first 30 days to ensue that they are adhering to the discharge instructions.




Medicare is Compensating Primary Physicians To Help Lower Readmissions. The Primary Physician is Well Equipped To Ensure Adherence To The Discharge Plan Except For When There is a Néed To Establish a Long Term Care Arrangement

• Coordination to ensure immediate follow up by the primary physician in order to determine that the patient is adhering to the discharge instructions and that there are no signs or symptoms of possible complications.

Pathways to Care brings Transitional Care Mangement Steps Beyond The Expertise of the Primary Physician

• Guidance for the family in choosing the right care arrangement.• Counseling to get the patient to agree to a safe care arrangement.• Family conflict resolution • Solutions on how to pay for the care• Med-Cal and VA benefits assistance • Solutions on what to do with the house






Transitional Care Management Day-by-Day Overview

• Introduce our transitional care management services

• Set telephone appointment for 2nd day Nurse Practitioner /Case Manager call

• Obtain discharge instructions

• Offer family use of our on-line patient management software

• Assess family concerns, plans and support commitment

• Answer any questions the family may have

• Invite the family to use our team as a resource

Prior to or on day of discharge, we contact the patient & the family





• Educate and explain any difficult to understand D.C. instructions

• Identify signs and symptoms of possible complications in order to provide early intervention instructions

• Ensure receiving home health care and/or non- medical home care visits are in place

• Patient has received recommended DME and supplies

• Patient has scheduled recommended doctor follow-up visits and has arranged transportation.

• Perform medication review and education

MD or NP to follow up at home day after discharge or2 Days after discharge a nurse will contact the patient to

ensure they understand and are adhering to the discharge plan





• Review for continued adherence to the discharge plans

• Ensure doctor and or specialist appointments have been made and transportation is arranged

• Identify signs and symptoms for early intervention

• Offer family counseling to assist with planning and preparing for the event that the patient needs long term care

Reassurance calls on 2nd, 3rd and 4th week after discharge and then quarterly as needed




Coordinating Care Across The Spectrum

Transitional Care Management isn't intended to replace any type of health care provider. Our strategy is to ensure effective planning and communication between the family,

doctors, hospitals, skilled nursing facilities, home health care agencies, social workers, in- home caregivers, assisted living facilities, RCFE's and other health care participants.





• Calls made by the nurse practitioner and health care coach are relayed to the patient’s primary physician

• Web based patient management software through which families, doctors and SPN can communicate and keep a log of the patient's status

• This software allows us to track and assign responsibility for carrying out each transitional care step

• As it is web based, all the relevant parties can easily see which steps have been completed and access important documents such as health insurance information, discharge instructions, medication lists and doctor contact information, power of attorney and trust documents.

Our strategy is to ensure effective communication between the family, doctors, hospitals, skilled nursing facilities, home health care agencies, social workers,

and other health care providers.




Transitional Care Management When Long Term Care is Needed

Enlist the support and cooperation of the family in overseeing the patient’s care and planning for the future

•Help for the family in choosing the right care arrangement whether its in-home care, board & care (RCFE), assisted living, or skilled nursing care. Education on the care options available in your area, how much they cost and which type is appropriate given the patient's care needs





Families often times face significant hurdles to succeeding at getting adequate care arrangements established.

•Guidance and assistance in getting the patient to agree to a safe care arrangement. We have a clinical social worker on staff with many years of experience working with dementia and Alzheimer's patients. We have developed techniques for both higher and lower levels of cognitive impairment to bring the patient to make the right choice for a safe living and care arrangement.

•Family conflict resolution: the counseling we provide in helping the family choose a care arrangement and to find a solution on how to pay for care naturally facilitates and resolves the reasons for most of the conflicts that families are facing during this stressful time.





Families are Looking for Solutions on how to pay for care

• Personal counseling with financial tools designed to help the family compare each care scenario side-by-side and make the best choice for their loved one. Patient's income, expenses, available assets, and government benefit eligibility is considered for each potential care arrangement such as home care, board & care, assisted living, or custodial skilled nursing facility care

• This tool is the basis for breaking-through difficult discussions between family member and the patient

.



Show families how to qualify for government financial benefits and assist with applications

• Families need personal help to apply and receive financial benefits such as long term Medi-Cal, non-nursing home Medi-Cal, VA Aid & Attendance pension, and VA in-home care

• Some families fail to go after these critical benefits as they think they won't qualify because they have too much in income or assets. They need guidance from a knowledgeable resource that can dispel the myths and demonstrate the legal and ethical options for obtaining eligibility and how it can help make their care choices possible

• Families need assistance with long term care insurance claim forms to help the family decide when is the appropriate time to submit a claim




lowering hospital readmissions…how we can help

We make locating quality care providers easy

We provide education on the long term care options that are available in the county and help the family to determine which are appropriate given the patient’s level of care.

We help the family locate quality care providers whether it’s in-home caregivers, home health care, hospice, assisted living, board & cares, and long term custodial skilled nursing facilities.

Some patients may have particular care needs or issues which make facility placement difficult. Not a problem, this is our expertise. We have a strong track record of matching challenging care situations with a welcoming provider.

Note that we also assist the family in negotiating the contracts and advocating on the client’s behalf when disputes arise.




lowering hospital readmissions…how we can help

Our greatest resource are our people. We have a highly trained staff with a wide variety of expertise that can make the

difference in coming up with a successful plan of action.

• RN’s• NP’s• PA’s, • LVN’s• LCSW• CPA• An attorney

• Medicare and Medi-Cal health insurance experts

• Real estate and mortgage experts

• Financial investment and management experts

• Placement Specialists

Throughout Southern California, this group works together as a team and can meet with the family in our offices, in the care facility, or in their home.

Among our staff we have




In closing

We need to go further in recognizing that care coordination is a collaborative

process supported by a multidisciplinary team and expand the support and delivery of services to the multiple

clinicians who provide those services

Working as a team we can help

Grow both of our organizations




National Transitions of Care Coalition (NTOCC) www.ntocc.org

Centers for Medicare & Medicaid Services (CMS) www.cms.govwww.cms.gov/Medicare/Medicare-Fee-for-Service.../FAQ-TCMS.pdf

Care Coordination and Registered Nurses’ Essential Role, Position Statement of the American Nurses Association. www.nursingworld.org/position/care‐coordination.aspx.

CMS Approves New Codes & Reimbursement for Transitional Care & Chronic Care Coordination.www.capitolupdate.org/index.php/2013/01/cms‐approvesnew‐codes‐reimbursement‐for‐transitional‐care‐chroniccare‐ coordination/. 2013 CPT® Codebook. American Medical

For information on how to start a extensivist program, go to:http://www.innovations.ahrq.gov/content.aspx?id=2903

Senior Places Network www.SeniorPlacesNetwork.com

resources

Thank you




Contact usFor more information or a free consultation

John Menzies Clark MBA,CPAExpert advisor on creating solutions on how to pay for the cost of senior care. With an expansive knowledge of long term care insurance, MediCal, VA Benefits and the aging process.

Elena Merchand, LVN,WCC, DWCExpert in finding local senior care facilities in Orange County with over 25 years of experience in the medical industry as a nurse, wound care and diabetic specialist and licensed administrator.

Visit us at www.Pathwasy2Care.com

or call714 408 4413

Health & Medicine

Presentation for Hospital Volunteers on Transitional Care Management