discharge planning is a family affair · discharge planning is a family affair: key roles and...
TRANSCRIPT
Carol Levine, Director
Kristina Ramos-Callan, Program Manager
Families and Health Care Project United Hospital Fund
Discharge Planning is a Family Affair:Key Roles and Concepts for Family Caregivers
101 Montgomery Street, Suite 2150
Francisco, CA 94104
800.445.8106 | 415.434.3388
caregiver.org
www.caregiver.org
United Hospital Fund works to build a more effective health care system for every New Yorker. An independent, nonprofit organization, we analyze public policy to inform decision-makers, find common ground among diverse stakeholders, and develop and support innovative programs that improve the quality, accessibility, affordability, and experience of patient care.
Created by UHF, Next Step in Care is designed to change health care practice by routinely identifying, acknowledging, training, and supporting family caregivers, especially at times of transitions in care. It provides practical advice and easy-to-use guides for both health care providers and family caregivers that focus on transitions between hospitals, rehabilitation facilities, nursing homes, and home. While New York is the primary focus of UHF and Next Step in Care’s work, the impact and relevance are national and even international.
www.nextstepincare.orgwww.uhfnyc.org
Regulatory issues that may affect hospital stay and hospital discharge
Why discharge planning is important and why family caregivers should be involved in decisions
Important features of good discharge planning
Factors in making decisions about Post-acute Care
Identify who can help when problems arise
Learning Objectives
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www.caregiver.org
Regulations That May Influence the Hospital Stay
Observation status means hospital outpatient services were given to help the doctor decide if the patient needs to be admitted as an inpatient or can be discharged. Observation services may be given in the emergency department or another area of the hospital. (CMS, 2017)
Inpatient vs. Outpatient Status: Inpatient means formally admitted with a doctor’s order.
Examples: https://www.medicare.gov/Pubs/pdf/11435.pdf
The patient has the right to be informed if they are on observation status
The patient’s admission status affects how much hospital services (like X-rays, drugs, and lab tests) cost, and how/whether rehabilitation services are covered under Medicare rules.
Refer to your latest Medicare & You handbook for coverage rates. Accessible at https://www.medicare.gov/sites/default/files/2018-09/10050-medicare-and-you.pdf
Observation Status
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At the Hospital — But Not Admitted? Ask repeatedly, “Has my family member been officially
admitted to the hospital, or is he or she under observation status?”
Make a note of each staff person’s response, including name & date.
NOTE: The hospital can retroactively (after the fact) change the patient’s status from inpatient to outpatient. This change is supposed to be made while the patient is still in the hospital, with a written notification to the patient.
If you do not receive this notification, or if you want to appeal the decision, you may want to refer to the Center for Medicare Advocacy’s “Self-Help Packet for Medicare “Observation Status”
Observation Status (cont’d)
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Caregiver Advise, Record, and Enable Act Law in 43 states and territories; provisions vary Intended to ensure that family caregivers are identified in
hospitals and trained to provide post-discharge care. Only applies to hospitals—so far
Four basic requirements1. Offer patient opportunity to identify a caregiver and
document the person’s contact information2. Obtain patients’ written consent to share medical
information with caregiver (written consent is not required in all states)
3. Inform caregiver about expected discharge date4. Provide instruction about care at home to caregiver
The CARE Act
www.caregiver.org
Hospitals are required to establish a safe and viable discharge plan even if the patient does not name a caregiver Hospitals are not required to delay a discharge because a patient has
not named a caregiver
If a patient names a caregiver The person identified by as a caregiver does not have to accept the
role. Instruction for post-discharge care may be provided in various ways,
including demonstration or video. This instruction may be helpful, but is unlikely to cover everything about post-hospital care.
Caregivers should communicate their availability, comfort, and willingness to provide care to the discharge planner
Does not create any new financial obligations to the caregiver
The CARE Act
www.caregiver.org
Bundled payment is a strategy used to encourage improved quality and efficiency of care at lower cost
A “Bundle” is a single payment for treating a specific medical condition across an episode of care
An Episode of Care includes all medical services provided to a patient for a particular condition within a specific period of time
Patients must be notified of participation in a bundled payment model per CMS rules
Examples of commonly bundled medical conditions: Joint Replacement Renal Failure or ESRD Cardiac Pacemaker implant
Bundled Payment
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No research yet to describe effects on patient experience. Health researchers theorize:
Drive to reduce costs may encourage providers to improve coordination and “most likely” lead to better patient experience
BUT Level of provider participation may limit patients’ choice of
physicians
AND Pressure to cut costs may lead to less time with patients or
decreased amenities, e.g. decreased length of stay; less intensive rehab services
Source: Bertko, J., & Effros, R. (2011). Increase the use of “bundled” payment approaches. Rand health quarterly, 1(3). Accessible at https://www.rand.org/pubs/technical_reports/TR562z20/analysis-of-bundled-payment.html#top
Bundled Payment (cont’d)
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Health Information Privacy and Accountability Act (HIPAA) Federal law to protect medical information from unauthorized use Does not prevent health care providers from sharing a patients
private medical information with family, relatives, friends or others the patient identifies as long as they are involved with his or her health care or responsible for health care bills
Does not require patient consent to share health information with family caregivers, as long as the patient does not object
HIPAA does not require proof of identity Health care providers may have their own rules for verifying who is
asking for information. https://www.hhs.gov/hipaa/for-individuals/faq/526/if-my-family-calls-my-health-care-provider-will-they-have-to-give-my-provider-proof-of-who-they-are/index.html
Caregivers Can Get Information They Need!
HIPAA
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Hospital Discharge Planning: The Caregiver’s Role
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Discharge Planning is a Family Affair
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https://www.youtube.com/watch?v=Un7As1R2-HU
Helps reduce risk for poor outcomes Readmission Medication errors Gaps in care Falls
Safe and adequate discharge plans are patient-specific Consider a patient needs as well as the family
caregiver’s: Availability and willingness Need for training Worries
Why is Good Discharge Planning Important?
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What is it? “A process used to decide what a patient needs for a smooth
move from one level of care to another.” – CMS Not just planning for a physical change in care setting, but
for a recovery period that may last a while
Who does it? Ordered by a doctor but can be carried out by SW, RN, care
manager or someone else
When does it happen? It depends!
Planned admission – some steps can be planned ahead of hospital stay
Unplanned – ongoing but patient and caregiver involvement usually starts a few days before the anticipated end of stay
Discharge Planning
www.caregiver.org
Preparing for Hospital Discharge
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Organize:
• Person’s health records
• Care planners/ schedules
• Medication lists
• Medical records and/or patient portal access
• Insurance coverage info
• Contact info – doctors, pharmacies, DME suppliers, etc…
• Copies of any advance directives
Note: some advance directives, like DNR, differ by setting and may require multiple versions (e.g. hospital vs. at home)
Make Sure the Provider Knows:
• Who the primary family caregiver is, and
• Caregiver’s contact information is on record and current
• Caregiver’s availability and capability to help with the patient
• Any professional health care services already engaged with the patient, such as home health agencies
Caregivers Can Self-Assess to Help Plan
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Caregivers Can Self-Assess to Help Plan
www.caregiver.org
Adapted from NSIC’s What Do I need as a Family Caregiver? at https://www.nextstepincare.org/uploads/File/Guides/Caregiver_Self-Assessment/What_Do_I_Need.pdf
Av
aila
bil
ity •Easy distance from patient?
•Do you work?
•Are you raising young children?
•Are you a caregiver to anyone else?
•Does your health affect caregiving?
•Can anyone else help?
•Are there other professional services involved with the patient? T
rain
ing
Nee
ds •ADLs (bathing, dressing,
toileting, hygiene and grooming)
•Mobility and Transfer
•Medication
•Equipment
•Care coordination
•Transportation
•Household chores and other tasks
Wo
rrie
s •Stress level and coping
•Work life balance
•Caregiving’s impact on relationships
•Managing medications
•Behavior (e.g. resisting care)
•Decision making, health and legal issues
•Safety and supervision (e.g. falls, wandering)
Care and services following hospitalization to continue recovery
At home, with nursing or services provided by a home health agency;
At a skilled nursing facility (SNF);
At an inpatient rehabilitation facility; or
At a long-term care hospital
About Post Acute Care
www.caregiver.org
Caregivers’ Most Common Concerns About Transitions to Post-Acute Care
www.caregiver.org
Timing
•May have had little notice of care transition, e.g. late notice of discharge or transfer
•Caregivers and patients need time to consider the options but time is never available
•Caregivers may simply be told, “We’re sending your mother to a nursing home,” causing extreme distress.
Information Available
•PAC choice guidance is limited, sometimes due to interpretation of anti-steering regulations
PAC setting choice
•Patients and caregivers may disagree about the choice of type of PAC setting or specific PAC facility
Care refusal
•Patients may even refuse home health care (almost a third in one study (Topaz, M., et al., American Journal of Managed Care; 21(5); 2015.)
Hospital to Home
Home with Home Care
Hospital Discharge: Going Home
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Getting home Know when discharge will take place
Prepare the patient’s home
Provide or arrange for transportation
Medical nursing tasks Coordinate home-based services like visiting nurse, physical
therapy, home-health services
Receive and set up medical equipment; learn how it works
Manage medications
Prepare special diets
Assist with mobility and other daily activities
Ongoing care coordination Be present for home-based service intake or initial visit
Know who to call, beyond the doctor, if there’s a problem
Schedule post-acute services like visiting nurse, therapists
Provide companionship or additional supervision
Caregiver’s Role in Discharge Planning
www.caregiver.org
NSIC Discharge Checklist at: https://www.nextstepincare.org/uploads/File/Guides/Hospital/Discharge_Checklist/Discharge_Checklist.pdf
Use a checklist To help with planning: keep track of task,
appointments, and new services
Ask questions and take notes keep track of who you talk to and when
Prepare for new needs Get training to manage medication, help with
mobility; prepare special diets
Get the home ready Install ramps, grab-bars or other supports, remove
falls risks, etc…
Plan for additional expenses e.g. medical equipment – find out what’s covered
Make a list of key contacts doctors, pharmacies, DME companies, home health
agencies
Get additional help if needed Think about what family, friends, and community
organizations might help with
Hospital Discharge Planning TipsFor Patients & Caregivers
www.caregiver.org
https://www.medicare.gov/sites/default/files/2018-07/11376-discharge-planning-checklist.pdf
Know Who to Call About the Discharge Plan
www.caregiver.org
Coordinate care, discharge planning, refer to social servicesSocial Workers
Liaise between patients and health care providers on patient rights, complaints, grievances, and conflict resolution.
Patient Advocate/ Patient Navigator
Advocate for older adults and persons with disabilities in residential facilities. www.ltcombudsman.org
Long Term Care Ombudsman
The Beneficiary and Family Centered Care-Quality Improvement Office handles Medicare appeals and grievances http://qioprogram.org/contact-zones.
BFCC-QIO
Legal analysis, education, and advocacy for older people and people with disabilities, have self-help packets for many kinds of Medicare appeal situations. www.medicareadvocacy.org
Center for Medicare Advocacy
National program with counseling, advocacy, and educational programs to help ensure access to care for older adults and people with disabilities https://www.medicarerights.org/
Medicare Rights Center
Getting a Post-Discharge Appointment Within Seven Days
www.caregiver.org
Ask Hospital Staff to:
Caregivers Can:
• Let the community provider know what happened in the hospital• Note that the patient/family caregiver will follow up for an appointment
• Call the provider’s office to schedule the appointment• Say why the appointment is needed right away• If you are having difficulty scheduling, ask to speak to a nurse or
other clinician• If you are still having difficulty scheduling the appointment, insist
on speaking to the doctor.Adapted from https://www.nextstepincare.org/uploads/File/Guides/Hospital/Post_Discharge_Appointment/Post_Discharge_Appointment.pdf
Medication reconciliation: the process of creating the most accurate list possible of all medications (RX and OTC) a patient is taking and comparing that list to admission, transfer, and/or discharge orders, with the goal of preventing adverse medical events. Source: IHI
Medication Management is how one ensures for any medications given the right patient the right drug the right dose the right route, and the right time
Medication Reconciliation & Management
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Seuss. (1986). You're Only Old Once!. Random House Childrens Books.
Skilled Nursing Facilities
Inpatient Rehabilitation Facilities
Long Term Acute Care Hospitals
Hospital Discharge: PAC in a Facility
www.caregiver.org
Difficult Decisions About Post-Acute Care
www.caregiver.org
https://uhfnyc.org/publications/publication/difficult-decisions-about-post-acute-care-and-why-they-matter
Decisions about PAC Matter to Patients
• Patients who receive care from lower quality providers have higher risk of complications and worse outcomes
• Choosing carefully can mean the difference between full recovery, cycling in and out of facilities, becoming a nursing home resident, or premature death
External Factors Limit Choice
• Insurance Constraints – Type or lack of coverage, benefit limits, authorization requirements, narrow networks, interpretations of medical necessity
• Capacity Constraints – Supply and capabilities of providers in a geographic area, availability of community services and supports
• Other System Constraints – PAC admission criteria, referral patterns/relationships between physicians/hospitals and PAC providers – e.g., ACOs, CJR, BPCI Initiative
What’s Important to Patients and Caregivers When Choosing a PAC Setting?
www.caregiver.org
https://uhfnyc.org/publications/publication/patient-and-caregiver-perspectives-discharge-planning/
• Convenient for family/friends; some willing to go further for specific services
Location
•Frequency of physical therapy; any special services available? e.g. ventilator, specific disease supports (e.g. ALS), on-site dialysis
Intensity and Availability of Services
•For patients who won’t be able to go home, is the PAC setting appropriate for transition to long-term care?
Ongoing Care
•Is the PAC facility in-network?•Will the facility take patients with expensive medication needs?
Finances
Consumer Tools to Understand PAC Quality
www.caregiver.org
Public sources on information
on Post-Acute Care
• CMS• Nursing Home Compare
• Home Health Compare
• State NH quality websites• http://www.calqualitycare.org/
(from UCSF School of Nursing)
• NYSDOH Nursing Home Quality Initiative
• ProPublica’s Nursing Home Inspect
Publicly available information
has limitations• Many websites, lots of technical
measures, less emphasis on aspects of quality that consumers find meaningful – e.g. quality of life, staffing adequacy, care coordination and communication
• Additional gaps – e.g., facility characteristics, patient/family experience and reviews, staff qualifications, access to specialists, staff interpersonal skills
Transitions don’t end when the patient gets home; they can last for weeks or months. Anticipating patient and caregiver needs in an extended transition may include
identifying community agencies that can help support the care plan.
Resources for Patients & Caregivers Post-Discharge
www.caregiver.org
Family caregivers provide essential emotional, physical, and other kinds of assistance for people who need long-term care.
They need assistance themselves to be able to do this demanding job well.
Care managers are the link to many medical and nonmedical services and supports for both person and caregiver.
Using the available resources can make everyone’s role easier.
Starting with UHF’s Next Step in Care at www.nextstepincare.org will give you many options to investigate.
Summing Up
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Thank you! Questions?
www.caregiver.org
Carol Levine [email protected] Ramos-Callan [email protected]
Created by UHF, Next Step in Care is designed tochange health care practice by routinely identifying,acknowledging, training, and supporting family caregivers, especially at times of transitions in care. It provides practical advice and easy-to-use guides for both health care providers and family caregivers that focus on
transitions between hospitals, rehabilitation facilities, nursing homes, and home. While New York is the primary focus of UHF and Next Step in Care’s work, the impact and relevance are national and even international. www.nextstepincare.org
United Hospital Fund works to build a more effective health care system for every New Yorker. An independent, nonprofit organization, we analyze public policy to inform decision-makers, find common ground among diverse stakeholders, and develop and support innovative programs that improve the quality, accessibility, affordability, and experience of patient care. www.uhfnyc.org
Family Caregiver Alliance offers education, services, research, and advocacy based on the
real needs of caregivers. Founded in the late 1970s, FCA is the first community-based
nonprofit organization in the United States to address the needs of families and friends
providing long-term care for loved ones at home.
National Center on Caregiving (NCC) was established by FCA to advance the
development of high-quality, cost effective programs and policies for caregivers in every
state. NCC sponsors the Family Care Navigator, a state-by-state resource locator designed
to help caregivers find support services in their communities.
Bay Area Caregiver Resource Center — operated by FCA for the six-county San Francisco
Bay Area — provides support to family caregivers. FCA’s staff of family consultants
through education programs and direct support offer effective tools to manage the
complex and demanding tasks of caregiving.
Be sure to visit FCA on social media:
About FCA
www.caregiver.org
facebook.com/FamilyCaregiverAlliance
twitter.com/CaregiverAlly
linkedin.com/company/family-caregiver-alliance
google.com/+CAREGIVERdotORG
youtube.com/CAREGIVERdotORG
Family Caregiver Alliance ofrece servicios educativos, de investigación, y abogacía basados
en las necesidades reales de los cuidadores. Fundada a finales de 1970, FCA es la primera
organización comunitaria sin fines de lucro en los Estados Unidos, dedicada a atender las
necesidades de familias y amigos que brindan cuidado a largo plazo a seres queridos.
National Center on Caregiving (NCC) fue establecido por FCA para promover el desarrollo
de programas y políticas de alta calidad y efectivas en costo que beneficien a los cuidadores
en cada estado. NCC es patrocinador del Family Care Navigator, un localizador de recursos
disponibles en los estados, diseñado para ayudar a los cuidadores a encontrar servicios de
apoyo en sus comunidades.
Bay Area Caregiver Resource Center — operado por FCA para los seis condados en el Área
de la Bahía de San Francisco — ofrece apoyo a cuidadores. El equipo de consultoras
familiares de FCA provee herramientas efectivas para sobrellevar las complejas y
demandantes tareas de ser cuidador a través de programas educativos y apoyo directo.
Asegúrese de visitar FCA en las siguientes redes sociales:
Acerca de FCA
www.caregiver.org
facebook.com/FamilyCaregiverAlliance
twitter.com/CaregiverAlly
linkedin.com/company/family-caregiver-alliance
google.com/+CAREGIVERdotORG
youtube.com/CAREGIVERdotORG
101 Montgomery Street, Suite 2150 Francisco, CA 94104
800.445.8106 | 415.434.3388www.caregiver.org