Smooth Moves: Stimulating Mindful Transitions from Hospital to Nursing Home. Your thoughts

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1 Smooth Moves: Stimulating Mindful Transitions from Hospital to Nursing Home Cari Levy, MD, PhD University of Colorado Department of Medicine Division of Health Care Policy and Research Denver- Seattle Center for Veteran- Centered and Value Driven Research (DiSCOVVR) Center of Innovation Your thoughts

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3 Objectives Understand barriers and facilitators to healthy PAC transitions Understand financial implications of transition to hospice in a nursing home Understand barriers and facilitators to provision of high quality end- of- life care in nursing homes The Landscape The National NH Landscape 16,000 nursing homes 1.7 million residents 70% over age 65yrs will require long term care 68% female 20% of all U.S deaths occur in NHs (60% hospital, 20% home)

4 The Colorado NH Landscape 17,000 residents 200 nursing homes UCH efforts to collaborate with facilities in the community Research efforts to improve navigation Hospice in Nursing Homes Less likely to be hospitalized (24 v. 44%) Better pain management Fewer physical restraints Fewer feeding tubes and IVs Miller SC, Gozalo P, Mor V. Am J Med Miller SC, Mor V, Wu N, Gozalo P, Lapane K. J Am Geriatr Soc Miller SC, Teno JM, Mor V. Clin Geriatr Med Miller SC, Gozalo P, Mor V. Synthesis and analysis of Medicare s hospice benefit. ASPE 2000.

5 Who Pays for the Majority of Nursing Home Care? A. Medicare B. Out of pocket C. Medicaid D. Private insurance E. Long- term care insurance F. HMO/PPO Medicare Part A Days Daily Cost to Beneficiary 1-20 $ $152 coinsurance 101 and beyond All costs

6 Who s Eligible for a SNF Stay? Medicare Part A Qualifying hospital stay 3 midnights, OBS status doesn t count! Hospice is also a Medicare Part A benefit concern about double dipping without different diagnoses Meet Marjorie and Bill 84yo female with severe dementia hospitalized after a hip fracture Hospital course complicated by aspiration pneumonia, new onset atrial fibrillation, new pressure ulcer and delirium resulting in a 12 day hospitalization Complete ADL dependence Family will have free care for 20 days if SNF stay used for wound care or rehabilitation from hip fracture

7 Bill requests an acute rehab stay Marjorie is not eligible He asks you to scan her head again There is no indication He requests more testing All medically indicated testing has been done You finally ask Bill what is troubling him about Marjorie s care Bill asks for your advice as he looks for a nursing home Which one is the best one in town? Can they manage all of her medical problems? How much will it cost? Will he go bankrupt? What if she doesn t get better? What can he do to get her the best care possible? Bill asks for your advice as he looks for a nursing home Which one is the best one in town? Can they manage all of her medical problems? How much will it cost? Will he go bankrupt? What if she doesn t get better? What can he do to get her the best care possible?

8 What is the best way to selecting a nursing home? A. Go with the social worker s recommendation B. Make an appointment with the NH admissions and marketing director C. Make an unannounced visit and take a good sniff of the place D. Have a look at the CMS website E. C and D

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10 Bill asks for your advice as he looks for a nursing home Which one is the best one in town? Can they manage all of her medical problems? How much will it cost? Will he go bankrupt? What if she doesn t get better? What can he do to get her the best care possible? What is the average monthly cost of nursing home care in Colorado? A. $4,800 B. $5,800 C. $7,800 D. $10,800 E. $12,800 Paying for a NH at EOL Hospice is required by insurers in Colorado (does not necessarily follow Medicare guidelines) Nursing home is rarely covered by insurers and average cost is $7,864 per month in Boulder/Denver metro area If an individual is single with less than $8,000 in monthly income and fewer than $2,000 in assets, they likely qualify for Medicaid (application can be expedited but required a period of Medicaid pending) Veterans who are hospice eligible are entitled to End- of- Life Benefit with nursing home payment covered in aby VA contracted nursing home

11 Hospice Reimbursement, cont. Medicaid Hospice The Medicaid Hospice Benefit mirrors the Medicare Hospice Benefit for Hospice services. Medicaid Room and Board Hospice bills Medicaid for room and board, then reimburses the LTC Facility. Private Insurance Plans verify in coverage. Hospice and SNF must collaborate regarding reimbursement issues. Hospice Reimbursement Medicare Hospice Benefit Reimburses hospice providing and managing all care related to the terminal diagnoses including visits by all hospice team members, supplies, medical equipment, and medications. Hospice required to pay ONLY for services that have been PREAPPROVED by the hospice program. Transitional Transposition Bill selects a facility and Marjorie is transferred on Friday afternoon He waits for the physician until late that evening and all day the next day Marjorie becomes confused Saturday evening Bill is informed that the Haldol was discontinued when she was admitted and morphine will not be available for awhile He demands that she be sent back to UCH

12 Who Cares for Nursing Home Residents? Certified nursing assistants Only 1 RN required 8hrs/day, regardless of facility size LPN s administering medications Change in condition Family advocacy is essential Workforce Challenges High Turnover Aides: 94% LPNs: 50% RNs: 59% High Vacancy Levels Contract Labor Costs Extraordinary Competition Compensation Disparity Hospital NFs Aides $30,831 $25,343 RN $65,097 $52,411 Expectation Conversation Not the same frequency of physician visitation Initial orders called to MD who does not know patient Often 72 hours before the initial physician visit Antipsychotics are difficult to justify in NHs Delirium worsen existing cognitive deficits 1 in 5 will be re- hospitalized in 30 days

13 Bill asks for your advice as he looks for a nursing home Which one is the best one in town? Can they manage all of her medical problems? How much will it cost? Will he go bankrupt? What if she doesn t get better? What can he do to get her the best care possible? No ADL Impaired All ADLs Impaired 136 (0.22) (0.42) W 268 (0.16) BW (0.13) 103 (0.21) BGW BGWT (0.13) (0.12) 96 BGWDT 134 (0.21) 198 (0.07) BGWDTS 319 (0.07) 184 (0.13) BGWDTSF 272 (0.11) 259 (0.31) BGWDTLSF (0.18) (0.40) B (0.20) (0.10) 113 (0.19) 112 (0.07) BGWD (0.16) (0.12) 216 (0.22) BGWDTL BGWDTLS (0.16) (0.25) 203 (0.27) (0.25) 127 (0.17) BGWDTLSU (0.07) ALL (0.39) (0.16) (0.05) 183 (0.24) 378 (0.04) 140 (0.39) G 245 (0.16) (0.24) (0.18) 227 (0.05) 196 BG (0.21) BGD 98 (0.09) (0.09) BGDT BGDTU (0.07) (0.18) 122 (0.10) 149 (0.09) 207 BGWDTU 171 (0.18) BGDTLU (0.21) BGWDTUS 198 (0.38) (0.16) 130 (0.18) 232 (0.16) BGWDTLUF 199 (0.10) 126 BGWDTLU 166 (0.04) Bathing (B)- Grooming (G)- Walking (W)- Dressing (D)- Toilet (T)- Bowel (L)- Bladder (U)- Transfer (S)- Feeding (F) 0.21) W 13.19) ) 201 (0.12) BGWD 143 (0.13) BGWDT (0.07) (0.13) (0.16) (0.12) 156 BGWDTL (0.07) (0.16) 259 (0.31) 216 (0.22) BGWDTLS 208 Days (0.11) BGWDTLSF 149 (0.16) 203 (0.27) (0.25) (0.17) BGWDTLSU (0.05) 183 (0.24) 314 Days to 274 (0.39) 314 (0.25) ALL GD BGDTU BGWDTU 207 BGWDTUS (0.18) 216 Days 232 (0.16) 198 (0.38) 216 (0.16) 98.09) 149 (0.09) BGDT 141 (0.07) 122 (0.10) 149 (0.09) 162 (0.18) 163 BGDTLU 171 (0.18) 207 (0.21) BGWDTLU BGWDTLUF 199 (0.10) 126

14 Probability of Recovery Based on Number of Acquired ADL Deficiencies 25 Probability of Recovery ADL Deficiencies Transitional Transposition What could we have done better? Bill selects a facility and Marjorie is transferred on Friday afternoon An expectation conversation He waits for the physician until late that evening and all day the next day An expectation conversation Marjorie becomes confused Saturday evening Indication for medications Bill is informed that the Haldol was discontinued when she was admitted and morphine not available Indications for medications, planning ahead for opioids, hospice eligibility? From our colleagues Your name and number = enormous value

15 Long- Term Care Regulations and Expectations of Hospice Services State Operations Manual (SOM) pp When a resident has elected the Medicare hospice benefit, the hospice and the nursing facility must communicate, establish, and agree upon a coordinated plan of care which reflects the hospice philosophy, and is based on an assessment of the individual s needs and unique living situation in the facility. Long- Term Care Regulations and Expectations of Hospice Services SOM, cont. The hospice must designate a registered nurse from the hospice to coordinate the implementation of the plan of care. This coordinated plan of care must identify the care and services which the SNF/NF and hospice will provide in order to be responsive to the unique needs of the resident and his/her expressed desire for hospice care. Long- Term Care Regulations and Expectations of Hospice Services The SNF/NF and the hospice are responsible for performing each of their own respective functions that have been agreed upon and included in the plan of care. The hospice retains overall professional management responsibility for directing the implementation of the plan of care related to the terminal illness.

16 Integrated Plan of Care Hospice service retains overall professional management of the plan of care related to the terminal illness. Integrated Plan of Care, cont. LTC Staff and Hospice Staff Collaborate Establish date and time to meet and formulate initial plan of care hours from admission to hospice. Collect data, encourage patient/family participation. Determine patient s DME, medication and treatment needs Designate discipline responsible for care. Identify payor source of items/treatments. Integrated Plan of Care, cont. LTC Staff and Hospice Staff Collaborate, cont. Develop and implement an integrated plan of care. Create and maintain communication system Hospice, LTC staff, pt/family, and physician set clear palliative care goals AND communicate them to all parties.

17 What is best for Marjorie and Bill? Objectives Understand barriers and facilitators to healthy PAC transitions. Understand financial implications of hospice provision in nursing homes. Understand barriers and facilitators to provision of high quality end- of- life care in nursing homes. Questions