Select Medical TRANSITIONS OF CARE & CARE COORDINATION

Transcription

1 Select Medical TRANSITIONS OF CARE & CARE COORDINATION

2 Agenda Select Medical Overview Transitions of Care Right Patient, Right Level of Care,Right Time Chronic Critical Illness Syndrome Role of Long Term Acute Care Hospital (LTACH) Care Coordination Pre care Point of Care Post care

3 Select Medical Overview

4 Select Medical s National Footprint As of 6/30/ Long Term Acute Care Hospitals (LTACH) (8 States) 7 Inpatient Rehabilitation,08 Outpatient 47 Contract Hospitals Rehabilitation Centers Therapy Locations 300 Concentra Centers (8 States) (3 States and D.C.) (8 States and D.C.) (38 States) 4

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6 Transitions of Care

7 Continuum of Care Right Patient, Right Level of Care, Right Time 7

8 Admission Scenarios Study Example 8

9 Chronic Critical Illness (CCI) High acuity, medically complex with multi organ system failure Frequently requires prolonged mechanical ventilation Distinct clinical group of patients with distinct pathophysiology and care needs when compared to acutely critically ill patients Post Intensive Care Syndrome (PICS) 9

10 Chronic Co-Morbidities Acute Critical Illness Medical Neurologic Chronic Critical Illness Ventilator Dependence Brain Dysfunction Neuromuscular Weakness Endocrinopathy Malnutrition Anasarca Skin Breakdown Symptom Distress Sepsis/Acute Co-Morbidities Surgical Cardiac Am J Respir Crit Care Med Vol 8. pp , 00 Older Age

11 CCI Discharge Options: CHEST, 005 Level of Care Acuity Level Advantage Disadvantage Acute ICU Patient may be unstable Hi Tech interventions as well as full ICU care (cardiac cath, Pulmonary Artery Cath, Full OR) Cost Focused on acute needs Not skilled in CCIS Acute Step-down Lower cost Patients usually stable Hi tech interventions with transfer back to ICU Focused on short stays Not Skilled in CCIS LTACH Patients may be unstable as long as acute care interventions not needed Specialize in CCIS Clinical Team and Patient Focused Lower cost Physician Coverage Patient focused Some focused interventions available (GI procedures, debridements, Respiratory procedures, basic diagnostics) Sub-acute SNF Patients must be stable Cost Family access Patient focused SNF Acute Rehabilitation Patients must be stable and recovering Must be stable and able to meet rehab criteria Cost Appropriate clinical services Rehab and mobility focused No on-site interventions, clinical team not skilled in CCIS and ratios much lower No daily physician coverage Staffing ratios No on-site interventions No daily physician coverage CCIS pt often not ready for this level

12 Role of LTACH Specialized ACUTE Care Environment Eid Evidence Based dtreatments t and Protocols Interdisciplinary Team Focus and Intensity of Service Patient Centered Serves a Critical Role in Facilitating Functional Outcomes Environment and Skillset for Early Mobilization of CCI Patients

13 Care Coordination

14 Care Coordination Focus and Innovation Pre Care Point of Care Post Care Screening Clinical Criteria Preparation Communication Facility Hand off Patient/Family Care Conference IDT Meeting DC Planning DC Preparation Communication i Patient Engagement Level of Care Clinical Capabilities Communication Patient Satisfaction 4

15 Point of Care Case Management/UR Organized Interdisciplinary Workflow Admitting Diagnosis Treatment Plan Discharge Planning Physician POC Progression Clinical Barrier Resolution Interdisciplinary Approach REHAB Severity of Illness Nationalized LOS UR/UM Treatment Plan Patient/ Family Case Manager Treatment Team Discharge Planning Resource and LOS Management Community Barrier Resolution Resource Barrier Resolution Utilization Review Outlier Management HOME DC LLOC OTHER SNF 5

16 Key Points Care Coordination Appropriate Transitions of Care Patient Centered Care Planning Multi Discipline Team Focused Treatment Plans Flow of Information and Education for Patients and Providers Innovations in Care Delivery and Coordination of Care 6

17 Thank you For additional information or questions: David Key, SVP Operations Select Medical 474 Gettysburg Rd Mechanicsburg, PA 7055 (77)