Community Resources

Linda Cragin, Director

MassAHEC Network

4-26-2013

Today’s Objectives

• Understand the importance of care transitions

• Understand the range of community services available.

• Understand how to access community services.

• Understand the important role of informal/family caregivers.

Care Transitions:

• Better coordination of patient transfers among care sites and the community could save money and improve care.

• Care transition describes a continuous process as patient care shifts from one setting to another.

www.healthaffairs.org

Care Transitions:

• Hospitalizations account for approximately 33% of total Medicare expenditures ($524 billion in 2010) and represent the largest program outlay.

• The Medicare Payment Advisory Commission estimated Medicare costs of approximately $15 billion due to readmissions, $12 billion of which is for cases considered preventable.

• Other estimates range from $25 to $45 billion in wasteful spending (2011) due to avoidable complications and unnecessary hospital admissions.

www.cfmc.org, www.healthaffairs.org

Within 30 days of discharge,

19.6 % of Medicare beneficiaries are re-

hospitalized.

Jencks SF, Williams MV, Coleman EA: Rehospitalizations among patients in the Medicare Fee-for-service Program. NEJM 2009 Apr 2; 360(14):1418-28

ACA impact on Transitions

• Effective 10/1/12: - Increase Medicare payments if hospitals

achieve/exceed targets for certain quality measures – including discharge processes and instruction

- Reduce Medicare payments by 1% if readmission rates readmissions rates exceed a target for certain diagnoses.

Care Transitions:Patient and Caregiver Involvement, Medication reconciliation, Handoff communication and Discharge, Preparing patients for Discharge, Teamwork and Interdisciplinary Rounds, etc.

Collaboration between the hospitals and their community partners to effectively co-design better processes of patient transfer.

The Care Transitions Program® - Transition Coaches® work with patients with complex needs and coach them with self-management skills to ensure their needs are met during transition from hospital to home.

So where do patients go?

Rehab Hospital• intensive inpatient rehabilitation

therapy• specialized care (3+ hours of therapy

a day) from a team (MD, RN, PT/OT) • Patient must have improvement

potential: stroke, spinal cord, brain injury

• Less likely: hip fracture, knee replacement unless there are complications

• Coverage: Medicare Part A

Skilled Nursing/Extended Care Facilities:

• Medicare covers skilled care for 1-20-100 days

• Medicaid, long term care insurance and private payment for long term/chronic/extended care.

• Team based care: Nursing, PT, OT, ST, SW, Recreational Therapist, pharmacist consultant, medical director

• Scheduled interprofessional care planning meetings with patient/family involvement.

SNF Medicare Coverage:

• Patient was formally admitted as an inpatient to a hospital for at least three consecutive days in the 30 days prior to admission in a Medicare-certified skilled nursing facility (not ER observation!); and 

• Medicare Part A covered the hospital stay

• Patient needs skilled nursing care seven days a week or skilled therapy services at least five days a week.

Critical opportunity for better transitions planning

Home Health Services: Skilled, Intermittent, Homebound

• Max: 8 hours/day and 28 hours/week. • Skilled nursing: performed by a

licensed nurseInjections (and teaching patients to self-inject), tube

feedings, catheter changes, wound care, etc.• Home health aide: if patient requires

skilled services. Includes help with bathing, toileting, dressing, etc. • Skilled therapy: performed by a licensed

therapistPT: gait training, regain/maintain movement and

strengthST: regain and strengthen speech and languageOT: regain/maintain the ability to do ADLs

• Medical social services• Coverage: Medicare Part A, no

deductible/co-insurance

Outpatient PT, OT, ST• Medically necessary • Medicare: if improvement or to

prevent deterioration• Limits! Medicare will cover up to

$1,880 for physical and speech therapy combined, and another $1,880 for occupational therapy.

• If patient approaches the limit and needs more, MD can tell Medicare that it is medically necessary

• Coverage: Medicare Part B

Hospice: • MD: life expectancy is <6 months (ALOS is 7 days!)

• Patient signs electing palliative care• Patient does not need to be

homebound• Comprehensive services delivered

by a team: RN, PT/OT/ST, pastoral care, social work, volunteers, respite, music and art therapists, massage, etc.

• Benefit includes two 90-day benefit periods followed by an unlimited number of 60-day benefit periods.

• Coverage: Part A

Medicare Advantage Plans• Health Maintenance Organizations (HMO)• Preferred Provider Organizations (PPO) • Private Fee-For-Service (PFFS) plans.• Special Needs Plans (SNP)• Provider Sponsored Organizations (PSO)• Medicare Medical Savings Accounts (MSAs)

In Massachusetts:Senior Care Options (SCOs)

Integrated Care Organizations (ICOs)

Program for All Inclusive Care for the Elderly (PACE)

Evercare

Some blend Medicare and Medicaid coverage…

Community Resources

Community Resources

• 1-800-age-info www.800ageinfo.org

Community Resources:

• Assisted Living and Supportive Housing

• Aging Services Access Points (in MA)

• Social Day Care or Adult Day Health

• Transportation

• Councils on Aging/Senior Centers

• etc.

Family Caregivers• Family caregivers are the foundation of long-term

care nationwide.• More than 65 million people, 29% of the U.S.

population, provide care for a chronically ill, disabled or aged family member or friend during any given year and spend an average of 20 hours per week.

• The value of these “free” services is estimated to be $375 billion a year; almost twice as much as is actually spent on homecare and nursing home services combined ($158 billion).

National Alliance for Caregiving 2009 various studies

Home Care, Nursing Home Care, Family Caregiving and

National Health Expenditures, U.S. 2004

$43 $115$306

$1,878

Home Care Nursing HomeCare

EconomicValue ofInformal

Caregiving(midrange)

Total NationalHealth

Expenditures

Expenditure data from Office of the Actuary, CMS, Smith C, et al., Health Affairs. 2006;25.

Bill

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f D

olla

rs

The typical family caregiver:

• A 49-year-old woman caring for her widowed 69-year-old mother who does not live with her.

• She is married and employed.

• Approximately 66% of family caregivers are women.• More than 37% have children or grandchildren under 18

years old living with them.

National Alliance for Caregiving 2009

Summary:

There are many community resources…

There are skilled, trained, professional staff caring across the spectrum of services…

Communication and coordination is critical…

Patient and family involvement is a must…

And… remember:

1-800-age-info www.800ageinfo.org