Module 2: Transitions Of Care Flashcards
Medicare Part A
-What it covers?
- Hospital insurance — Covers medically necessary hospitalizations, SNF, Home health, and hospice care
Medicare Part B
-What does it cover?
- Medical Insurance — Covers medically necessary doctors services, preventive care, durable medical equipment, hospital outpatient services, lab tests, x-rays, mental health care and some home health and ambulance services
Medicare Part C
-What does it cover?
- Not a separate Medicare benefit
- It is the Medicare Advantage part of Medicare
- This allows private health insurance companies to provide the same benefits as original Medicare
Medicare Part D
-What does it cover?
- Outpatient prescription drug insurance — Only provided through private insurance companies who have contracts w/ the government
- Each plan covers a different formulary of drugs
Transitions of Care
-Definition
- Movement of a patient from one set of providers, level of care , or health care setting to another
- “Handoffs” “Transfers” - Can occur w/in the hospital setting or across health care settings
Suboptimal Transitions of Care
-Stats?
- 1 in 5 older adults discharged from the hospital is re-hospitalized w/in 30 days
- 1/3 are hospitalized w/in 90 days
- Cost of unplanned re-hospitalizations to Medicare is estimated at $15 billion/year
Common Barriers to Safe Transitions?
- Diverse Needs
- Lack of provider education and feedback - No DC summary or lack of knowledge of capabilities of post acute care settings
- Difficulty communicating — with colleagues at previous or next site of care
- Lack of time or financial resources — lack of reimbursement in US system
Optimal Transitional Care
- Contains elements of care coordination, discharge planning, and disease or case management
- Focuses on highly vulnerable and chronically ill populations
Components of Optimal Transitional Care?
- Accurate and timely transfer of information to the next set of providers
- Empowerment of the older adult to assert his or her preferences
- Comprehensive assessments of older adult and caregiver needs
- Comprehensive medication review and management at each transition
- Logistical arrangements related to executing the transition
- Education to prepare older adults and caregivers for what to expect at the next site of care
- Support for self-management of medical conditions
- Coordination among medical community resources
- Follow-up and support after DC
Discharge Destinations
- Home w/ family support
- Home w/ home-health care — Medicare requires that older adults receiving home-health care be homebound*
- Custodial Care — Assisted living or nursing home or long term care — PRIVATE PAY or long term care insurance/ Medicaid
- Skilled-Nursing facility (SNF)
- Medicare requires these patients need a skilled services
- Covers SNF up to 100 days after qualifying hospital stay — Different for Advantage plan
- Coverage stops earlier if treatment goals are met or pt is not meeting goals - Acute Rehab hospital — To qualify, pt must be able to do 3 hours/day of intense therapy
- Long-term acute care — Rare pt who requires mechanical ventilation, multiple IV meds, parenteral nutrition or complex wound care
- Inpatient Hospice
Discharge Medication Regimen
-What to Include?
- Indication for each medication
- Stop dates or tapering schedules as appropriate
- Clear behavioral triggers as-needed psychiatric meds
- Meds added during hospital stay for use as needed or for prophylaxis can be tapered or DC’d
- Formally reconcile w/ the pre admission medication regimen
- Clearly document
- Medications that are new since admission
- Pre-admission medications that have been stopped
- Dosages of continued medications that have been changed
Info to Communicate to Pt’s and Caregivers
-When DC is directly to home?
- Follow-up appointments
- Warning Sx’s or signs to watch for, w/ instructions on whom to contact
- Clinical disciplines (Nursing PT) contracted to provide services in the home
- Reconciled medication list
Info to Communicate to Pt’s and Caregivers
-When DC is to another Care setting?
- Nature of the new institution
- Identity of the new attending physician (if known)
- Expected frequency of provider visits
Look up Caretransitions.org
Info to Communicate to Pt’s and Caregivers
-Direct communication to New caregivers?
- Critical but pending study results
- Nuances of goals of care
- Family dynamics
If the above are fine,
-A brief, prompt DC summary is good
—Include a summary of hospital course w/ care provided and results of important tests
—List of problems and diagnosis
—Functional and cognitive status at baseline and at dc
—Reconciled med list
—Allergies
—Test results still outstanding And follow-up appointments
—Goals, preferences and advance directives
—Best contact info for the Discharging clinician in case any questions arise
3 Steps to Improve Transitions **TEST
- Set expectations — for both sending and receiving provider teams
- Shift concept of DC to “Transfer w/ continuous management” - Tailor communication strategies — to Type of information being communicated and type of transition
- Target specific processes — or outcomes for improvement, using established QI methods
