Long term care mid term

2 types of care
1. delivered in hospital (acute)
2. extended/chronic/long-term care – care outside the hospital setting

reason for increase in long term care
hospitals dont get as much money

goal for acute care
get them fix- curing and fixing

long-term care
– want to help maintain the level of functioning they are currently at
-maintaining functional independence and for you not to decline
– usually not curing you

goal of long term care
promotion of functional independence
– to enable the patient to maintain functional independence at the maximum level that is practicable
-very individualized services

length of services
short term services
long term services

short term services
– less than 90 days
-rehabilitation, physical therapy
-stand alone rehab
-post-acute convalescence or stabilization

long term services
holistic care and quality of life are critical
-long stay extended period of time
– individual not just physical
– most long term care are received out of nursing homes

basic facts
-14% of those needing LTC receive care in nursing homes
– 42% of LTC users are under the age of 65
-aging does not trigger the need for LTC
-it is multidimensional

informal and formal care givers
– informal – most are this, family taking care of you, no one went away to get taken care of
-formal – clinician, hired to work and take care of you

-public charity based on english poor laws
– served those with disabilities mostly
-run by local governments
-squalid conditions
-board of charities to oversee them
– later the mentally ill were separated

social security act
– indirectly started long term care bc states got grants to start taking care of long term patients
-federal grants to states
– pay for needy, disabled, elderly
-ended the poorhouse system
-indirectly started the private home industry

hospital survey and construction act
hill – burton 1946
– grants to build new hospital, but had to provide services to everyone
– not around anymore but hospitals must still abide by the giving services
-federal grants to states to build new hospitals
-many old hospitals were converted to nursing homes

long term really started because of

in 1950a
-federal funds were provided to build nursing homes
-social security amendment:OAA money to be paid directly to nursing homes
– enabled nursing homes to contract with the state to deliver care to the poor
– nursing homes were required to be licensed

– nursing homes became part of us health care
-government became the largest payer of LTC
– community based care was difficult to regulate, hence policy favored nursing homes
– investors developed nursing home chains
-many did not need nursing home care, but were institutionalized
-utilization and public expenditures exploded

medicare and medicaid
– to participate in the public programs, nursing homes had to comply with new standards
– federal law mandated states to license NHA’s

who gets the good or bad wrap long-term care or short term care?
long term care – gets negative view, bad wrap
– partially their fault and not their fault
– never tried to make themselves a value to the industry
acute care – gets the better wrap, they get more funding
there was the accountable care act that originally has the class act that was all for giving funds to long term industry, that was cut so now nothing for long term care

clients for long term care
older adults
– those in fair to poor health are likely to need LTC – 25% of the elderly
– assessment of disability
– ADL’s for institution
– IADL’s for independent living
– ADL’s and IADL’s – determine need for long term services

activities of daily living
– ex: can’t feed, dress, walk by yourself anymore
– can’t take care of your body functions

independent living
instrumental activities of daily living
-might be independent in feeding, walking, etc but cant cook cook, drive, grocery shop

losing informal care givers
bc they are working,cant afford to stay home and take care of them

clients for long term care
children and adolescents
– birth – related impairments
– mental retardation

children can be both
– living arrangements
– school arrangements

clients for long term care
young adults
– neurological malfunctions
– degenerative conditions
– injuries
– many mr/dd victims enter adulthood
– community based dwellings are more appropriate for MR/DD clients

Clients for long term care
people with aids/HIV
– aids will receive long term care services
– now a chronic condition
– mortality has decreased
– special challenges: depression and other psychiatric disorders, dementia, weight loss, incontinence

clients for long-term
-people needing subacute or high tech care
– subacute care
– ventilator care
– head trauma and comatose patients
– alzheimer’s
people with chronic care issues

LTC is continuum
patient’s placement is determined by:
– extent of disability
– client preferences
– availability of services
– ability to pay

who determines a lot of what services will be received

The LTC continuum
1. informal
2. community based
3. institutional

-family make up largest % of long term services
– peoples homes – least intensive
– not organized, not really a system
– most of the care is unpaid
– not financed by insurance or public programs
– delivered by family
-mostly basic care
-enables people to live independently

community based
takes on various forms – people come in your home to provide services
ex: comfort keepers – in home services
or ex: go and take them to adult day care
– go somewhere and then come back still live at home

most live in faculty that provide services
– most intense to go to a nursing homes or go into a boarding home/ assisted living

the continuum
– can’t just freely go in between these three bc of :
– regulations
– want rational integration

The institutional system
main types of facilities:
– independent/ retirement facilities
– personal/residential care homes
– assisted living homes
– skilled nursing facilities

subacute care facilities
-services previously available only in hospitals
– cheaper alternative to hospitals
-acuity level in higher than in skilled nursing facilities

specialized care facilities
– nursing homes that specialize in a given type of care
– ventilator care, Alzheimmer’s, intensive rehabilitation
-ICF/MR facilities provide specialized programming for MR/DD patients

5 distinct LTC services
1. medical care
2. mental health
3. social support
4. residential amenities
5. hospice services

1. medical care
– physicians, nurses
– needed after an acute episode
– to manage chronic conditions and prevent complications

2.mental health services
– 2/3 patients have mental disabilities
– common mental conditions:depression, anxiety disorders, delirium, dementia
-adequate delivery poses several challenges
– appropriate training of staff

3. social support
– assistive and counseling services
– to help people cope with change
– deal with stressors
– grieving can be a normal part of the transitional process

4. residential amenities
building layout
– compensate for people’s disabilities
– support services may be available
– basic amenities:
– space, privacy, safety, comfort, cleanliness
-other amenities
– homelike environment, social activities, recreation, decor

hospice services
-end of life care
– for terminally ill (life expectancy is < 6 months) - a cluster of services - medical, legal, financial, spiritual, social support - emphasis shifts to palliative care - patient and family are treated as one unit

interaction btw LTC / Complementary Services
LTC should be rationally linked to the rest of the health care continuum

rational integration
– clients must be able to move freely
– goal, but we struggle with it
– want to move freely in to and out of long term care services
– move from institutional to community freely between the continuums

rational integration btw
-non-long term care services and long term care care services
– long term care services that are independent and institutional

Current system has strengths
– provides much needed care to a large, diverse population
– open to consumers needs and wants
– dedicated caregives
– increase in focus on customer service

current system has weaknesses
– reimbursement driven
– poor image
– inadequate support for care givers
-lack of educational support for caregives

cost of LTC services
-very expensive
– medicare was never set up to pay for long term care, it was for short term care

main payer in long term care
medicaid is the largest payer

what is a nursing facility
-facilities with 3 or more beds that routinely provide nursing services

nursing facilities
– licensed by the states offering room, board, nursing care and some therapies

– SNF – skilled nursing facility – not every facility is skilled
– ICF – intermediate care facilities
– ICF- MR – for mentally ill

difference btw SNF and ICF
– SNF higher services, people that work there must be licensed, more intense services
– SNF is required to have RN on staff 24/7, state mandated
– ICF’s dont have that requirement

Evolution of nursing facilities
-started more when money was available
– have bad image in public
– industry did take advantage
– highly regulated- highly structured
– vulnerable population
– increased regulation
-still under scrutiny

philosophy of care
medical vs. social model
– focus more on social
care vs. cure – focus more on caring for entire person
– encourage family involvement – have meetings for care for individuals
– multidisciplinary approach

classification of nursing
according to certification
– medicare certified – COP’s set by federal government – so you can take medicare patients and receive funding
– medicaid – not too many around
– dully certified – majority are this medicaid and medicare
– state licensed only

classification of nursing
according to association
– free standing – not connected to anyone on your own
– unit of hospital – can have one within hospital or on some property
– multilevel services – different types can stay in continuum of care
– chain – HCR manner care – largest chain in Pitt

classification of nursing
according to ownership
– largely for profit – most run by for profit organization about 70% only in it for the money
– goal is to make money for their investors
– not for profit – 20% usually run by religious organizations – most faith based
-few government 6% ex: veterans

3 basic types of nursing home admissions
– short term recovery
– terminal or hospice care
– long term residency based on functioning levels

short term recovery
– rehab people with hip, knee replacements that cant stay in hospital or cant go home yet
– average length of stay around 23 days also for strokes very elaborate rehab unit

terminal or hospice care
end of life care if cant stay at home 24/7 care
– close services

long term functioning
– go and live there based on daily living and disabilities
– nursing care

services provided:
– nursing
– medical dental
– medications
– labs and xray
– room and board
-therapy – PT,OT, speech, recreational

special care units
by diagnosis:
– alzheimers
– mental health and retardation
-brain injury
– aids
by age:
– young adult

direct care staff:
– unlicensed -CNA – usually this for bathing, everyday stuff
– licensed – RN/LPN – administer medication and treatments
ancillary staff:
– housekeeping
– dietary

if nursing staff gets in trouble home must tell
state database

senior management:
– NHA – 21 yrs. old – go through classes and take national test, must be licensed by state
– nursing

other professional staff:
– social workers
– case managers
– dietitians

primary sources of reimbursement:
– medicaid – 70%
– private – usually 2nd type of payment – out of pocket
– medicare – 13% not really set up for long term care
– perspective payment systems
– set amount of reimbursement
– medicare part a

medicare coverage
– covers only skilled nursing care
– rehab, IVs, woundcare
– doesnt pay for someone to get out of bed and dress them
– must follow 3 day hospital stay physician order, observation days dont count
– limited to 100 days per benefit period
– pays 100% from 1 to 20 days
– requires co-payment for 21-100
– 2014 co-pay = 152.00
– after 100 days – you pay everything
– if get home and then realize that you need a nursing home you still have 30 days to get in the nursing home

medicaid coverage
– nursing/medical services
– standard room
– pharmacy services
– dietary
– routine personal hygiene supplies

registered nurse assessment coordinator
– huge assessment on patient done for everything
– RNAC – does this

resource utilization group
– put in group and paid based on what RUGS you are in for medicaid
-could have long term care service

need the right type of case mix
cant have the same type of patients in nursing homes

very little money from medicaid
doesnt really cover operational cost

Medicaid pays
nursing services = standard room, private room is own cost
– pharmacy dietary, activities, and routine personal hygiene supplies – very basic

categories of regulation
-regulations pertaining to reimbursement
– regulations pertaining to residents
-regulations pertaining to building safety and construction
-regulations pertaining to employees

regulations pertaining to reimbursement
– federal/state (COP) – conditions of participations set by federal government dictates everything

regulations pertaining to residents
residents rights
– clinical assessment MDS
– determines needs and care person must get

regulations pertaining to building safety and construction
– to make sure care is safe

regulations pertaining to employees
-very demanding type of work
– employees have rights as well
– employees education

management challenges
– balancing cost and quality
– balancing resident mix
– ensuring satisfaction
– integration of differing levels of service
– coordination with other facilities and organizations

balancing cost and quality
hard to balance cost and quality
– very limited moneys not very high reimbursements
– EMR – want this dont have money for it though

balancing resident mix
cant have all medicaid etc.. need enough balance of diff. types of patients

ensuring satisfaction
-difficulties people that are in there for the long time hard to keep patient satisfaction

integration of differing levels of services
aging in place – less disrupting to try and allow in facilities for as long as possible
– hiring highly trained staff, can you do that

coordination with other facilities and organizations
-not well integrated – different organizations competing

types of legal/ ethical issues
– day to day issues
-end of life issues

day to day issues
autonomy (choice)
-residence choice – sometimes cant allow patient to have total autonomy bc it impacts someone else
– patients can leave whenever, usually have to pay for it though
– medicaid cant get private room

end of life issues
advance directives make sure there are living wills, durable power of attorney
Patient Self Determination Act – what they want done at end of their life
-needs are much greater now for people coming into these

significant trends
– rising acuity levels
– managed care
-reimbursement issues
– prospective payment
– private insurance
– rising liability costs
– consumer choice
– eden alternative

eden alternative
10 yrs ago – resolves around making facility just like home as much as possible

post acute care
outpatient services
– any care outside hospital after being discharge – service delivered on outpatient basis
– rehab facilities
– LTCH – free standing

Long term care acute hospital
– intense care for extended period of time – ALOS > 25
– specialized services
– reimbursement
– licensed as acute care hospital

high needs, very intense care, are licensed as regular hospital, licensed as acute care hospital, some requirements, reimbursed through medicare
– usually on ventilators, critical care unit outside of hospital

subacute care
– comprehensive inpatient post acute care
– areas btw acute and long term care
– it is delivered inpatient post acute care, very defined period of time
– developed to save cost – what brought it in
– provided in free standing skilled nursing facilities

ownership of subacute services providers
– mostly provided in freestanding SNFs (2/3)
– rehabilitation focus
1/5 hospital – based
– medical focus
many owned by corporate chains

4 levels of subacute care
length of stay – determines levels mostly
– transitional
– general subacute
– chronic subacute
– long term transitional subacute

-usually in hospital, usually short stay – reimbursed by medicare, one aspect of hospital to another
-transferring resident from a highly intense unit to another unit in hospital still requiring fairly intensive care

general subacute
– provided in nursing care home, usually longer 30 days
– longer stays then transitional

chronic subacute
– 60 to 90 days
– provided in a nursing home

long term transitional subacute
– usually in hospitals
– extended stays
– very extended 6 month

examples of subacute services
– rehabilitation
– wound management
– ventilatory support

focus of subacute
services are very goal oriented
– care planning
– focus on quality of care and outcomes frequent patient assessment
-initial assessment
– interdisciplinary team
– weekly team conferences
– ongoing evaluation
– very frequent patient assessment

key to effective subacute services
case management is the key
– very focused
2 goals: efficiency and cost effectiveness
– 1 persion managed for patients care
– manages resources to optimize outcomes at lowest cost

case manager may be
internal – hired by provider
external – hired by payer

types of regulation/ accreditations for subacute
state and federal
– subacute licensed as a skilled nursing facility
accreditation by:
-the joint commission

what is the most payer of a skilled nursing facility
medicare – 2/3 pays as SNF
other – managed care, medicaid, private pay and other sources

licensed by the state as nursing facility administrator
– no exception for hospital based units

interdisciplinary team
– program administrator
– physician
– other professional staff
– non licensed staff

long term care hospital
regulated and surveyed as an acute hospital

who runs a subacute?
nursing home administrator license

what are the regulations?
licensed as a skilled nursing hospitals

The Continuum of Housing Special Populations
independent vs supportive
what determines the decision?
– functionality
– financial standards
– physical features of home
– service linkages
– environment

do you need help or can you function alone? physically or mentally

financial standard
8/10 elderly today still remain in their homes

physical features of home
– how is house set up – is there stairs?
– most try to adapt environments as much as possible
– aging in place – stay where you are adapt
– physical property, bring services to the people, home modifications

service linkages
– services to bring into home
ex: meals on wheels determining if it is accessible to you

physical of where i live
– safe to live by themselves
ex: snow can they get out is someone plowing

Independent Housing Options
– what financial mechanism is out there that helps seniors stay in their homes
– reverse mortgages – help seniors stay in house and be independent

reverse mortgages
– allows seniors 62+ yrs
– allows to take money out of equity of your home and use money to modify home or services to come into your house
– you still own house
– pay back only when leave house ,if you die and house sold you have to pay back whatever you borrowed
– Fred Thompson does reverse mortgages ad

Independent Housing Options
– senior apartments
– age restricted retirement communities
– independent living residences

senior apartments
is there additional services? no
– just rent monthly apartments
– for smaller living spaces and for SOCIALIZATION

age restricted retirement communities
55+ to get into a lot of these
– large community
– still independently
ex: The Villages, St. Barnivous

Independent living residences
– larger organizations
– can be on a campus or by itself
– still fully functionally

Housing assistance – government
section 202 housing – financially supported by federal gov’t in 2 ways:
– only supported housing for seniors 62+ yrs only supportive services
– must be 50% monthly income or less of median income range in Pitt needs to be 17,000 or less
-seniors still pay a monthly rent usually 30 % of whatever income they are getting
– cant be profit organization, they are private, non for profit
– usually faith base organization -usually Catholic church
– they can provide you supportive services
– partnership btw senior and federal government

supportive housing
– personal care
– assisted living

personal care
– prohibited from providing acute medical care
– up to 2011 personal care and assisted living were same, now not anymore
– usually mom and pop organizations
– basic services food, housing, transportation – NOT MEDICAL CARE

assisted living
– philosophy of care – designed to focus on aging in place -allowed to stay there as long as possible
– licensed have requirements for services and structural requirements
– have regulations
– services provided are housing, nutrition, medical care, social service care
– licensed by Dept. of public welfare, no state dept of health
– most are for profit
– not licensed by federal government
– dont take medicare

assisted living cost structure
– 90% for profit organization – need to make money
– tiered costs or change assistance
– all inclusive rate
– ala carte charges
– hourly charges

tiered cost
most common cost structure today
– majority charge monthly basis renting
– Tier 1 includes services
– Tier 2 includes other services
– decide on needs what tier should be purchased

all inclusive rate
doesnt really happen anymore
– manager lost money bc people required more services than anticipated

ala carte charges
pick services and pay for what you want

hourly charges
only usually used for health services only need something for an hour or 2 a day

Assisted living to provide medical services
– no medicaid, all private pay organization
– no national regulations for assisted living co.
– govt has no involvement, all regulated by state in PA dept of public wealth

national organization that lobbies for assisted living
ALFA – assisted living federation of america
– some are accredited – TJC, CARF, CCRC
– assisted living is more organized

management challenge and trends
– money huge challenge
– can do fundraisers balancing cost they charge
– managing medical needs
– challenge btw autonomy and independence vs managing personal needs

CCRC vs. Life Care Communities

– continuing care retirement communities
– ideal community to live in – most can’t afford

Life Care Communities
– people will never have to leave even if they run out of money
– provide all series of services

CCRC provide
provide continuum of services usually on one distinct campus
– nice concept independent living to skilled nursing services all in one spot

2 diff. btw CCRC and LCC
– in LCC dont own property, CCRC have opportunity to buy house
– entry – do pay a certain amount to join this community – sometimes depend on income it can range 10,000 – 400,000
– monthly – pay this into addition – determined by services your using, size of property

Supportive housing contracts
– life care/ extensive
– modified/ continuing care contract
– fee for service contract

life care/extensive
– covers unlimited long term nursing care – little or no cost to individuals
– most expensive, least risky
– contracts are life long and binding – subsequently anyone in organization usually seek a lot of financial and legal guidance before you sign contract
– risk – most expensive contract but least risk
– 60s to 70s very independent when signing
– a lot of analyzing and looking at attributes, not entered in lightly
– most expensive, least risky****

modified / continuing care contract
– relatively healthy going in
– only need nursing care for specified time
– after time gone and need services you will pay costs
– medium price, medium risk****

fee for service contract
– least expensive, most risky***
– residents pay separately for all health and medical services and for long-term care, services stipulate what you pay for

CCRC regulations and accreditation
– state regulations
– state and federal regulations for nursing facilities within CCRC
– can have TJC, of CARF

other state agency that oversees Life Care Communities
its almost like insurance policy
– governed by insurance companies

physical disabilities
most services provided determined by separate service system from origin of disability

types of disabilities
– congenital – born
– developmental – 22 or younger
– acquired – pick it up
– can determine service provider

Policy Issues
– very instrumental in developing services for these people with disabilities

rehab act legislate
people with disabilities had employment OT and live independently
-ADA can discriminate
– Olmstead – legislative people with disabilities can not be institutive against their will

Financed Services
SSDI- social security taxes – payroll taxes – if havent worked wont get it
SSI – financed through general tax revenues – everyone can get this

mental illness
burden of care
housing options

burden of care
providing services fall on 2 entities
– state and community responsible for taking care of mental retardation

housing options
ICF-MR – intermediate care facility
– very few around
– provided through community organization or outpatient care basis
-needed to integrate people into regular environments

HIV/AIDS focus of treatment
case management
– will be receiving care for rest of life

core measure for case management
– for necessary services for long term basis
– client identification
– distinctly identify 5 parts
– medical and psychological need****
-someone must be assigned to individuals to make sure getting right services
– development of service plan

– medicaid – biggest financier
– Ryan White Act – last resource of financing for these people
-every yr they look at how much money put into fund
– enacted 1990

– HUD – authorize housing
– poverty and HIV high correlation

Dept of Veteran Affairs
separate population – due to demographics focus on geriatric services, very distinct services
– largest health care organization in the US

Veterans Service
Geriatric Research Education – very good – everyone veteran goes under evaluation determine most appropriate services needed
– have inpatient and outpatient

2 aspects that integrate VA
1. sharing of medical records – technology
2. case management – every individual has a case manager follow their care
– integrated structure

VA financing
-VERA – pays for them
– 3rd party payers if necessary
– sometimes co – payments for non service related treatments and medications

minimal data sets
– asses what their needs not paid by this, just formality
– do it bc state look for it

Children in long term care system
bc of special needs
– difference in continuum of care in there for a long time
– obligated to provide services and families and schools

some specific hospitals for children with long term care
– St. Judes – cancers
– Shriners – orthopedic disabilities and burns

special educational factors
– school for death – shady side
– children institute – provide school
– school for blind – bell ave
– schools receive federal funds on services for these children

childrens with special needs for financing
– medicaid – main provider * financial criteria is determining factor
– Title V Social Security Act – grants go to state, they are responsible dividing up funds
– TANF – cash money funds
-SCHIP – provides insurance for children with families with low income
– defined plan on how to allocate funds

whose primary giver is non institutionalize services?
family members

market forces that are diving community based services
– consumer choice – most prefer to be at home and have services come to them
– finances – cost effectiveness
– social and demographic changes – may not have ability to family take care of you
– competition among providers
– ex: UPMC have their own community based line to keep in baseline – vertical integration

Adult Day Services
when mom lives with kid but kid works so has day services come in

background of ADS
– based on respite concept – family given a little free time

goal of ADS
support informal care givers (family)

ADS ownership status
– most ADS are not for profit

ADS affiliations
– doing vertical integration

models of ADS
social model – senior centers – provides activities some provide meals some don’t

Adult Day Health Care
– medical model
– do provide medical services – do have medical director, RN, LPN

dementia specific
for Alzheimer and dementia patients

ADS standard of operation
open mon – fri, not weekends
– open normal working hours 7- 6 allow people to drop off and pick up

ADS staffing/ personnel
usually have director, activity aid, staffed by volunteers
– a lot are faith based

medical health care model
– have dietitian, physicians, nurses, medical director, consultation, rehab, PT, OT, speech provide services
– still allow families to be primary giver

Licensure, Accreditation
– no medicare reimbursement
– no federal regulation
licensed by state
– in PA – regulated by Dept of aging

accrediation if they provide rehab

ADS fees/ financing
– 70.00 a day contracts can be for everyday, 3 days a week whatever
– forms of reimbursement
– long term care insurance
– non operating revenue services
– united way and fundraising to get money

PACE model
– ADS model
– all inclusive care for the elderly
-55 yrs or older
– Life Pittsburgh responsible for PACE
– stipulations
– service jurisdictions
2 criteria:
– financial and medical
– serve people low off medicaid population need some functioning level
– take care of ALL care if eligible

ADS administrative challenges
– where do they get money
– donations
– how do you market to get your people in there
– staffing – need to be creative

Home care, Home Health and Hospice
cost efficiency
– market force
– home health home based services is way cheaper

home care
supportive services only – dont deliver medical care
– shopping, clean house, pharmaceutical

home care staffing
private duty agencies – can be a combo
– might just sit with individual while care giver is away

home care certified
medicare certified
– governed by federal and state
– dept of health certifies and surveys – surveyed every 36 months
-COP. delineate type of services, billing
– Accredited by TJC, CHAP, ACHC

eligibility criteria for home care
– physician order
– care cant have nurse 24/7 must be intermittent < 8 hrs a day - homebound - cant be able to go to outpatient setting must be confined to home - medicare beneficiary - not in criteria hospital stay - like it is for skilled nursing services

services for home care
– skilled nursing – must be provided by licensed professional
– rehab- OT, PT, speech
– home health aid – dressed, bathed, etc

Home care reimbursement
– #1 payer is medicare – not set up for skilled nursing, this is what medicare was set up for

Medicare reimbursement
– OASIS – determine services, functional status
– form filled out determines reimbursement you will get for that person
– clinical severity, functional status, need for rehab
– 60 day episodes – some money up front, then 60 day episode, then close case

medicaid reimbusement
– home health is an automatic benefit
– can get community wavier – if not qualified through medicaid
– capitated payment
– private- out of – pocket

home health is the #1 sight for
fraud and abuse

quality reporting
must report to federal government
– big thing to look at discharge rate

quality initiative
– empowers consumers to make educated choices
– stimulates providers to improve quality
– established quality measures for reporting
– established QIO’s

admin challenges in home care
– payment lag times- not reimbursed in timely period
– staffing issue – difficult to hire people in home health, bc of driving places, going to shady places,not under constant supervision,
– patient non compliances, responsible for what happens even if patient doesnt cooperate
– regulatory issues, patient safety and rights

-all about how you live – quality of life at the end stage, not how long
– provides dignity and working with family

hospice specialized
home health services

hospice philosophy
-not a program, focus of services

palliative care
comfort measures, focuses on pain management
– hospice involves this

hospice history
doesnt hasten death
– started by dr. sicill
– should be recognized in a good way when leaving life 1983 – medicare benefits
– not just for cancer patients

medicare certified

medicare certified
-state survey you every 2 years
– federal
– accredited – TJC, CHAPS – by some bodies – CHAPS would be cheaper

diagnosis using hospice
– renal failure, COPD, prognosis of 6 months or less life expectancy

eligibility criteria
certified as terminally ill
– have diagnosis you wont get better
= individual cant seek active treatment anymore – curative treatment
– medicare beneficiary

benefit periods
– 2 (90) day periods – 6 months
– guaranteed coverage for 6 months
– unlimited 60 day periods for as long as qualify medically
-continue to show deterioration

– medicare – part a
– private insurance
– medicaid

levels of care
– routine- services done in the house, reimbursed off of per visit – every day
– continuous – 24/7 near end life – reimbursed $910 a day – profitable business
– inpatient respite – primary care giver – still family patient admitted to hospital for 5 days to give family a break of care one respite stay per 90 day period
– general inpatient- family can no longer provide care, so admitted to hospital or skilled facility have own internal unit – near end life

who receives money
-if inpatient respite how does hospital get paid ,hospice has to give money
– for inpatient respite and general inpatient – hospice usually makes contract for how much covered per day

services to patient
– at no cost to patient or family
– wonderful benefit
– even medications contracted by pharmacy – meds shipped to house
– therapy no curing you, but help you live a better life until the end
– huge volunteer services – go sit with family read to people
– bereavement services – help arrange funeral services
– 2 yrs after death contact family and provide services in whatever way they care

how does hospice know whats going on
– interdisciplinary team meetings
– every 2 weeks discuss every client you are servicing
– written care plan for every patient – care and outcome, family issues
-very closely knit services

new requirements for hospice
– a lot of money to hospice
– quality reporting
– April 2014 every hospice must submit quality reporting
– 1 structure measure – do you have infrastructure measure – usually used for licensing requirements, measures the services available or # of nurses certified
– 1 pain measure – collect pain measure on every admission
– will impact reimbursement rates – definitely will affect reimbursement rates

biggest challenges
– access to care – people dont understand the concept of hospice
– so many people can benefit that dont understand they can use hospice
– length of stay – dont stay long – lot work for short stays, patient never gets real benefits
– palliative curative distinction
– staffing unique person to work in hospice

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