Home Assessments Resulting in a Positive Effect on Outcome Score Cards
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2 Home Assessments Resulting in a Positive Effect on Outcome Score Cards Presented by: Angela Benson, OTR/L, Clinical Specialist *graduated from Mount Aloysius College, Cresson, PA *9 years of experience with Allstar Therapies *Occupational Therapist in Skilled Nursing and Home Health Settings *Rehab. Manager *Clinical Specialist *Clinical Auditing Welcome and Thank You for Attending!
3 Provider Information Allstar Therapies, Inc. is a leading provider of contracted Physical, Occupational and Speech Therapy services in Skilled Nursing Facilities and Home Health Agencies. Allstar provides therapy services to facilities ranging from 120 to 400 beds and over 40 Home Health Agencies in multiple states. Ability to contract with any Home Health agency to create a partner in health and patient choice. Provides continuity of care through therapists in multiple settings.
4 Today s Agenda Biggest Concerns Facing Facilities Today Home Assessment vs. Home Evaluations The Overall Impact of the Home Assessment Home Assessment Facility Goals What Impact Has the Home Assessment Had On the Facility/Patient Outcomes
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6 Partners in Health and Wellness What are the biggest concerns that our facilities face today? Hospital readmission rates Admissions Patients Length-of-Stay (LOS) Discharge and Functional Scores Reimbursement for services provided Bundled Payments: CJR Model (Joint Replacement, Cardiac Care) Goals include becoming a trusted, efficient provider with decreased readmissions, decreased length of stay, and a valued discharge partner Patient s pathway home Continuity of Care Inadequate Home Health therapy team Caregiver Support Considering the Presidential Debates and Being Days Away from the Election: Impact on Obama Care
7 Partners in Health & Wellness New Facility Admission: Discharge process begins even before the admission takes place Choose the appropriate pathway for a successful discharge home Pulmonary, Cardiac, Orthopedic, Falls Prevention, CVA Also, Home Assessments Program, We Follow You Home Home Assessments vs. Home Evaluations Skilled Nursing vs. Home Health What is the difference?..is there a value?
8 Example Clinical Pathway Program
9 Skilled Nursing Rehabilitation: Home Assessments A Home Assessment is defined as: A complete analysis of the patient s residence, family residence, for safety concerns, architectural barriers, to enhance improved communication and results. A Home Assessment is a vital part of the rehabilitation process ensuring the safest discharge to the home environment to a known environment and to the care of a known therapist
10 Skilled Nursing Rehabilitation: Home Assessment Marketing information provided to all potential referral sources Reviewed with patient and/or family during admission process Scheduled within hrs with family Completed within 48 hours of admissions Available < 24 hours following admission Visits coordinated for morning/afternoon/evening as indicated by family Home Assessment duration: minutes Results reviewed with Interdisciplinary Team < 24 hours following completion Home Assessment completed by Occupational Therapist from SNF and Home Care Teams
11 Home Assessment: Facility Goals Home Assessment Program Facility Goals to improve: Communication/relationship with family on goals/outcomes Individual Patients and facility overall discharge score Individual Patients and facility length-of-stay(los) Patients functional outcome gains (as well as, Section GG of MDS admit/d/c score) Hospital readmission rate % Therapy efficiency, documentation and functional goals Facility admission and Marketing Dashboard Rating in Post Acute Care
12 Home Assessments: Occupational Therapist Occupational Therapist completing Home Assessment is scheduled to be the same clinician who follows resident home post discharge. Home Assessment Goals for OT: Assess patient/family s home for any modifications/measurements (stairs, furniture, doorways, etc.) Recommendations for adaptions to environment to ensure safest function within home Recommendations for alternative home set-up during recovery process (first floor setup) Determine additional training needs for caregiver/patient for successful transition home (what is specific focus in therapy, main goals) Review environment for potential Durable Medical Equipment (DME) needs during SNF stay and upon discharge Educate family members on expected outcomes, goals, facility LOS, and adaptations recommended for a safe discharge home Provide realistic functional information to IDT to improve delivery of POC and admission/discharge scores in Section GG
13 How Well Do You Know What The Data Reveals? 1. Nearly Medicare beneficiaries are readmitted to the hospital within 30 days of an acute hospitalization. a. 1 in 5 b. 1 in 8 c. 2 in 7 2. Discharge planning occurs the patient is discharged from the acute care hospital and throughout the hospital stay. a. when b. before c. after 3. Adverse events related to are among the leading causes of hospital readmission. a. falls b. dietary precautions c. medication management 4. Medicare data suggests that 39% of older adults transfer between different care settings in the 30 days after hospital discharge. a. usually once b. 2 or more times c. Twice 5. Specific recommendations upon discharge are necessary in the discharge summary for adequate home care carryover. Specific recommendations from Physical Therapists, including those regarding the needs for assistive devices for further PT services, are completely missing from of discharge summaries. These omissions are associated with increased risk of hospital readmission. a. 25% b. 40% c. 55%
14 References within the article from the PT Journal, Volume 96, Number X, Article, Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions from Hospital to Community 1 Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360: Polnaszek B, Mirr J, Roiland R, et al. Omission of physical therapy recommendations for high-risk patients transitioning from the hospital to sub-acute care facilities. Arch Phys Med Rehabil. 2015;96: e3 4 Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc. 2003;51: Coleman EA, Min SJ, Chomiak A, Kramer AM. Posthospital care transitions: patterns, complications, and risk identification. Health Serv Res. 2004;39:
15 Skilled Nursing Rehabilitation: Home Assessments In two of our Skilled Nursing Facility settings: Example 1: 90% of discharges with home assessments resulting in improved outcomes scores and returning home and 10% of patients discharged to assisted living Example 2: 87% of discharges with home assessments resulting in improved outcomes scores and returning home and 13% discharged to assisted living No hospital returns or readmissions
16 Home Assessments: Results Post Acute Care Score Card Estimated Length of Stay (ELOS) Average ELOS = Average ELOS variance = 3.5% Discharge Score: Actual Discharge Score gain: 2.75 Discharge Score Variance <6% Functional Outcome Gains Average improvement: Clinical Pathway - Cardiac, Orthopedic, Falls Prevention FOM Gain: 2.33 Gain %: 52.80
17 Allstar Therapies, Inc. Dashboard Example Results Allstar Therapie s, Inc. Dashboard Results ELOS TARGET ELOS ELOS Variance Discharge Score DC Score Variance DC to Community 30 day readmit Pre Home Assessment Post Home Assessment Variance Pre Home Assessment Post Home Assessment Variance ELOS TARGET ELOS ELOS Variance 39.73% 5.00% 34.73% Discharge Score DC Score Variance DC to Community 38.00% 62.00% 24.00% 30 day readmit 30.80% 14.80% 16.00%
18 Home Assessments: Results Hospital Readmission Rate Facility Average 15% Patients with Home Assessments <6% Therapist Efficiency/Documentation Home Assessment patients: Improved functional activities with POC Documentation Accuracy Facility Admission and Marketing Support Admissions increased by 14.5 % Admissons
19 Thank You/Questions?? Allstar Therapies, Inc. is looking forward to becoming your Preferred Provider. For questions, comments, or to learn more, contact our office at or Allstar Therapies, Inc Ader Road Penn Township, Pa (P): (F):
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Transitioning Care to Reduce Admissions and Readmissions Sven T. Berg, MD, MPH Julie Mobayed RN, BSN, MPH Disclaimer: Potential for Error Type One Error Rejecting the null hypothesis when it is true
Re-Hospitalizations and the Bottom Line: What SNFs Can Do to Get Ready. Maureen McCarthy, RN, BS, RAC-CT, CPRA President & CEO Celtic Consulting
Re-Hospitalizations and the Bottom Line: What SNFs Can Do to Get Ready Maureen McCarthy, RN, BS, RAC-CT, CPRA President & CEO Celtic Consulting OBJECTIVES Define Rehospitalization and discuss current statistics
EVALUATION OF THE POST-ACUTE CARE PATIENT
EVALUATION OF THE POST-ACUTE CARE PATIENT Taylor Bailey, NP-C Jessica Reed, NP-C AGENDA What is Post-Acute Care? Why Post-Acute Care? Post-Acute Care: Who Belongs Where? Overview of Post-Acute Care inpatient
Test bank PowerPoint slides for each chapter Instructor guides for each chapter (with answers for discussion questions and case studies)
This is a sample of the instructor materials for Dimensions of Long-Term Care Management: An Introduction, second edition, edited by Mary Helen McSweeney-Feld, Carol Molinari, and Reid Oetjen. The complete