discharge planning

what are some things that pts have difficulties with that may make it hard for them to be discharged home?

self-care management

mobility

nutrition, ADLs

caregiver support

dressings, meds

high tech equipment

how does the affordable care act respond to 30 day readmits?

1-3% penalty on all medicare charges if rates >average

in 2013 HF, AMI, pneumonia

2015 COPD, elective total hip arthroplasty, total knee arthroplasty

what are the possible discharge options?

long term acute care hospital (LTACH)

inpatient rehab facility (IRF)

skilled nursing facility (SNF)

high tech home care

home with visiting nurse

assisted living

home no assistance

what is an LTACH?

extended rehab for clinically complex pts: neuro, multiple trauma, ventilator weaning, post total hip/knee

located within/outside hospital

requirements: insurance (medicare eligible), require extended rehab (>25 days), likely to return home

describe IRF

free standing hospital or specific unit in acute care hospital: spinal cord injury, stroke, major trauma, amputation, post transplant

must tolerate 3 hrs intense rehab per day

medicare: complicated payment formula, based on LOS, dx, comorbidities

what is a SNF?

provides skilled nursing care/rehab often part of wing in nursing home

medicare: 3 day hospital stay, 1st 20 days all costs covered, 21-100 days 80% costs covered, after costs not covered

what is a nursing facility/home?

provides room, meals, help with ADLs when physical/mental problems prevent living on one’s own

termed custodial care

not covered by medicare: spend down assets, then covered

when is a high-tech aide service used?

an adult w/ spinal cord injury on a ventilator and with a feeding tube

child w/ cerebral palsy on CPAP machine

adult w/ ALS w/ a track and feeding tube

describe the job of a visiting nurse

need to be “home bound” for reimbursement

limited number of visits

limited period of time

home care nurse provides: demonstration of care, returns at intervals to check status, and is typically not their daily

what is assisted living?

falls somewhere between independent living and a SNF

housing and fee for meals, meds, dressings, bathing, personal care, etc.

may combine independent living, assisted, and a SNF in one facility

not covered by medicare

who is involved in discharge planning?

patient and family

health care team: MD, NP, RN, case manager/social worker

insurance provider

post acute care facility or home care team

describe the role of the case manager

interacts w/ pt, healthcare team, third party mayors, hospital admin

goal is to get something cost effective and a quality treatment

interprets insurance benefits

obtains authorization

educates pt regarding LOS

proposes alternatives for care

what does the staff nurse do during discharge?

determine pt’s baseline function prior to admin

assess post discharge care needs

assess support system and availability

discuss transportation issues

assess need durable medical equipment or home health services

identify any spiritual or cultural issues

communicate w/ case manager

what is discharge planning actually like?

process often fragmented, highly variable, and haphazard

newly discharged pts were developing complications that led to readmission

areas to be improved: pt education, communicating plan to PCP, system to insure post discharge plan followed

what is a discharge advocate?

makes appointments for followup care/tests at times and locations convenient and practical for pt

discusses tests/study results w/ pt

reconciles discharge plan w/ national guidelines and clinical pathways

insures PCP accepting responsibility knows plan of care

give pt a user-friendly discharge plan

assesses pt understanding by teach back

provides phone reinforcement 2-4 days after discharge

what is palliative care?

indicated at any age for anyone w/ a serious, life threatening illness when cure is no longer possible and symptoms pose significant burden and cause poor QOL

main goal is to relieve pain and discomfort, reduce family stress, and improve QOL

considers emotional and spiritual needs

define curative care

focuses on recovery and prolonging of life

what is hospice?

life limiting illness

prognosis is 6 months or less if disease takes normal course

pt wants hospice: consents to accept services

list the services hospice provides

pt/family focused

interdisciplinary team

provides a range of services: case management, medications/pain relief, medical equipment, medical supplies, volunteers, grief support

additional: inpatient, inpatient respite care (for caregivers), home care visits, residential care facility, complementary therapies, specialized pediatric team

who pays for hospice?

medicare could pay all costs

Medicaid could pay all costs

insurance: most private have a hospice benefit

private pay

what does the nurse do for a pt in hospice?

support pt and family

advocate to: physician, pt, family