Out Of Office Care. Ati Hakimi MD,MBA Geriatric Physician Associate Medical Director PPD Las Vegas, NV

Transcription

1 Out Of Office Care Ati Hakimi MD,MBA Geriatric Physician Associate Medical Director PPD Las Vegas, NV

2 Disclosure Statement-none

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4 Question 1 What does not constitute out of office care? A.Group Home B.Long term care facilities C.Assisted Living facilities (ALF) D.Cruise doctor E.Skilled Nursing facilities (SNF)

5 Learning Objectives 1.Describe common problems that occur in the out of office patient. 2.Discuss care of patient following admission to long term, subacute or extended care facilities and coordinating care with other practitioners. 3.Discuss transition of patients between health care organizations and provision for safety and quality of care for patients in all settings. 4.Discuss appropriate use of care team (ie home health).

6 Fun Facts about Seniors! Per the CDC, by 2050 Americans aged 65 or older will be nearly 89 million An estimated 12 million Americans need long term care By 2050 number of individuals using LTC will reach 27 million Projected LTC total spending will be $346 million in 2040 In 2003 Medicaid paid $83.8 billion for LTC services

7 What is a SNF? Two classes of patients (subacute or LTC) Staffing LPN s, CNA s, PT/OT/ST, SW, administration, activities, providers (MD/DO or midlevel) Strengths: 24/7 care, licensed caregivers, Weaknesses: little privacy, not covered by LTC insurance Cost: $ a day if LTC or Medicaid eligible, 20 days if insured with HMO then co-pay about $150/day, if Medicare up to100 days Medicare allowable: $171-$194 per visit

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9 What is not a skilled need? 1. IV antibiotics 2. PT/OT/ST 3. Placement (not safe to be home alone) 4. Wound care

10 PLACEMENT IS NOT A SKILLED NEED!

11 Subacute SNF Skilled needs are: 1.IV antibiotics (ie osteomyelitis, PNA, wounds) 2.Wound care (ie daily wound care, wound vacs) 3.PT/OT/ST (ie s/p acute CVA, THA, TKA, debility/falls)

12 What can a subacute SNF do? Anything the hospitals do!! Especially with advent of DRGs (except pressors, intubation, inserting tubes, transfusions,dialysis) Very few consultants

13 Medicare mandates for subacute SNF Medical needs see patient everyday Non- medical needs 3 x / week

14 Common Problems 1. Discharge 2. Families 3. Transition back to primary 4. Prevention of readmission

15 Solutions 1. Sending complete discharge summary to PCP 2. Communicating services in SNF to families at admission 3. Providing HH (PT/OT/ST or wound care) services for patients to go home with 4. Educating what ER/UC is for 5. Discussing end of life care when necessary

16 But Mom isn t safe to go home alone.

17 Long Term Care (LTC) in a facility Advantages: 24/7 care with medical personnel at all times, daily activities, more socialization Problems: providers only see patients once a month, acute needs become emergent b/c providers don t respond in timely manner Solutions: providers responding more promptly to acute needs

18 What is a Group Home? Two subclasses chronic disabilities (needs help with ADLS) or memory care Usually 6-10 residents per home Staffing: 24/7 caregivers not necessarily medical Cost: $ (Medicaid will pay some) Medicare allowable: $190-$156 Strengths: 24/7 care, home environment, locked/alarms for memory care, Weaknesses: not medical, limited activities and outside socialization esp. if memory care, no tubes/pegs

19 Problems 1. Quality of care 2. Quality of group homes/licensing ( income dependent) 3. Non-medical staff (ie dispensing meds or medical emergency) 4. Little family involvement

20 Solutions 1. Providers increasing visits/ quality of care 2. Making sure facility is licensed and all staff know CPR and how to dispense meds 3. Encouraging families to be more involved

21 What does HIC home stand for? 1. Home for Individual Care 2. Home for Intensive Care 3. Home for Independent Care 4. Home for Immediate Care

22 What is a Home for Individual Care (HIC) home? same regulations as group home but limited to two residents more specialized for residents with g-tubes, tracheotomies Strengths- home that offers 24/7 care Weaknesses-not always medical personnel Cost $ per month per resident Medicare allowable- same as group home

23 What is an Assisted Living Facility (ALF)? Two subclasses: Independent vs Memory Care Staffing: 24/7 Caregivers, nurses available, activities, administrators Cost: $ per resident (plus any add-ons) Medicare allowable: $190-$156 Strengths: 24/7 care, independence w/ available medical staff (ie call buttons), more socialization w/daily activities Weaknesses: expensive

24 Problem and Solutions Problems: even though 24/7 access to care maybe difficult for acute issues quality of care provider dependent Solutions: more frequent visits by providers or medical offices in facilities to see patients for acute issues education of providers for these patients

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26 Question 2 Who is an ideal home health patient? A.89 year- old with dementia who has had fall at home and broke her hip requiring therapy? B.65 year-old with poorly controlled DM now has osteomyelitis of left foot? C.75 year-old with OA who had an elective knee done at home and has family support? D.70 year-old with recurrent falls at home and no family support?

27 C! All others are ideal for SNF!

28 Medical Home Care Services- PT/OT/ST, nursing care, home safety checks, vitals, labs (INR checks), wound care, IV antibiotics (based on insurance) Covered by Medicare Staff- medical professionals Strengths-available to all patients, way to follow patient at home who is not debilitated or has memory issues Weaknesses-quality of medical homes cares varies

29 Barriers to Practice There are no standards of care for out of office care- provider dependent Inconsistent quality of care Cost of seeing patients out of office (time, driving, lack of resources, coordination with facility) Shortage of providers willing to go out of office Transition of care

30 Best Practice Recommendations - Coordinate quality of care with out of office facilities to improve quality of life for patients - Visit patients more routinely than the minimal once a month recommendation - Encourage families to be involved in the care of their loved ones - Utilize home health when appropriate

31 Answer Key 1. D 2. C

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