4/12/2019 1 Seamless Transitions of Care: Strategies for Successful Outcomes Susan LaGrange, RN, BSN, NHA, CDONA, FACDONA, CIMT, IP-BC Director of Education Pathway Health Objectives 1. Describe the elements of the discharge planning process from admission to discharge to home 2. Identify helpful transition tips for a successful discharge 3. Assist family and resident with preparation to discharge home 4. Understand person-centered care planning requirements This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only. A Little History This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only. 1 2 3
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4/12/2019
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Seamless Transitions of Care: Strategies for Successful Outcomes
Susan LaGrange, RN, BSN, NHA, CDONA, FACDONA, CIMT, IP-BC
Director of Education
Pathway Health
Objectives
1. Describe the elements of the discharge planning process from admission to discharge to home
2. Identify helpful transition tips for a successful discharge
3. Assist family and resident with preparation to discharge home
4. Understand person-centered care planning requirements
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
A Little History
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Why focus on transition of care?
• Can lead to adverse events
• Higher readmission rates
• Higher costs
• Miscommunication
• Can occur from any setting
• Patient satisfaction
Transitions of Care
What are transitions of care?
Movement of patients from one health care practitioner or setting to another as their condition and care needs change
Transitions of Care
Occurs at multiple levels• Between settings: Hospital ↔
Sub-acute facility/SNF, Hospital ↔ Home
• Within settings: ICU ↔ Ward
Across Health States• Curative care ↔ Palliative
care/Hospice
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Common Care Transitions
Key Components of Care Transitions
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HRRP, SNFVBPThis presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice
with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
Quality
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
Transitions of Care Begins with Discharge Planning
F624 Orientation for Transfer or Discharge
“A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand.”
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
• Providing a good explanation of the location of discharge and the reason
• Ensuring resident’s belongings go with the resident (or safeguard)
• Staff provide services to prevent or minimizes anxiety
• Resident is provided preparation for transfer in a manner that they can understand
• Document resident understanding of the discharge
https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/som107ap_p
p_guidelines_ltcf.pdf
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
F660 Discharge Planning Process
“The facility must develop and implement an effective discharge planning process that focuses on the resident’s discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions.”
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
F660 Discharge Planning Process
Discharge needs are identified
Include regular re-evaluation
Involve the Interdisciplinary
Team
Consider caregiver availability, capacity
and capability
Involve the resident/resident
representative
Goals and treatment
preferences
Interest in receiving information on returning to the
7ap_pp_guidelines_ltcf.pdfThis presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice
with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
“If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.”
“For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data..”
“The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident’s goals of care and treatment preferences.”
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
Definition
“Discharge Planning”:
A process that generally begins on admission and involves identifying each resident’s discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident’s stay to ensure a successful discharge.
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
• Not all residents can be discharged to another setting
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Discharge Care Planning
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Policy/Procedures for Discharge Planning
Example:• Policy: It is the policy of
this facility that an effective discharge planning process will be conducted with the resident and/or resident representative as active partners, focusing on the resident’s goals and preparation for resident centered care following discharge
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
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Procedure
Procedure:
• Resident comprehensive assessment
• Person-centered discharge care plan developed
• Referrals
• IDT to re-evaluate
• Selection of destination
• Documentation
• Discharge Summary
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Discharge Plan
Interdisciplinary Team + Resident + Resident Representative
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A Good Discharge Plan Starts At the
Time of Admission
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Destination-Home
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
Resident Admission
Creating a Person-Centered Approach to Transition of Care!
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Admission
Gather information on:
• Prior living setting
• Plans for discharge
• Assistance needs and availability
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The First Step to Success
Make sure that you and the
resident/patient are on the same page
Discover
Needs
Goals
Preferences
Expectations
Does the resident and their caregivers/family
members have the same goals
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Begin The Assessment Process!
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RAI PROCESS
MDS
CATs
CAAs
CARE PLAN
CAA SUMMARY
CARE ASSESSMENTS RESIDENT INTERVIEWSThis presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice
with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
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Steps for a Safe Transition
Home!
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
Transition Care Plan
• Do you have a formal transition of care plan?
• Is there consistent education across shifts?
• Is there a process for communication with all members of the care team ?
• Are you confident you have documentation to substantiate progress and process?
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
The Home Environment
• Do you have a process to discuss the home environment with the resident and their caregivers?
• Have you completed a home visit to identify:• Safety needs/barriers?• Mobility needs/barriers?• Resident motivation?
*Develop an individualized plan to overcome any barriers and opportunities for successful transition!
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Preparing for Medical Management
• Education in chronic disease management
• Understanding of medical conditions • Signs and
symptoms of trouble
• Communication with Providers • When to call, who
to call • Health monitoring
• E.g. blood glucose monitoring
• Medical treatments • E.g. nebulizer,
wounds, etc.This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice
with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
Managing Social Care Needs
• Financial needs
• Support structure
• Access to care- Transportation
Assess social aspects of health
• Local Area Agency on Aging
Have resources available to
describe resources in the
community
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Discharge Planning
Resident Teaching• Medications
• Treatments
• Devices
• Routines
• Etc.
• Functional Interventions
• Resident Representative Teaching
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Considerations
Resident Cognition
Function
Motivation
Endurance
Available Support
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Cognitive Health
• Does this individual have a dementia diagnosis or a mental health diagnosis
• Education of the caregiver
• Referral to resources
• Alzheimer’s Association
• Caregiver support groups
• Booklets on behavioral management
• Local groups for the individual to get involved with
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Practice and Repetition
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Start Education Process-ASAP!
• Education of your resident (and caregivers) is key to their success
• Education must be coordinated and consistent
• Start teaching now • A little every day
• This is an advantage to our setting
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Plan-Medication Teaching
• Name
• Dose
• Time
• Route
• Special instructions
• Side effects or special considerations
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Key education topics
• Their medical conditions
• Key warning signs • Medications
• Key side effects
• Mobility • Safety
• Etc.
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Day of Discharge
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
Tasks for the Day of Discharge
• Communicate with the Medical Provider in the Community
• Give contact info to the resident (e.g. nurse case manager or social worker)
• Assist with scheduling follow up appointments
• Provide educational packets• Medication information• Disease specific
information• Treatment instructions• Etc.
• Ensure that everything you have planned for is in place • Transportation • Support• Home health • Durable medical
equipment • Medication list • Mobility aides • Etc.
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
Discharge Instructions-MDS 3.0
• Identification
• Contact information
• Advance Directives
• Physician Name
• Pharmacy
• Care Provider Contact
• Medical History
• Medications
• Treatments
• Durable Medical Equipment
• Housing
• Transportation
• Follow-up appointments
• Contact information at Nursing Facility
• Medication education
• Disease management education
• Who to call in an emergency
MDS 3.0 RAI Manual, Pages Q-9-10This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
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This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
Post-Discharge Follow-Up
Your Role
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Follow Up Is Essential!
• Ensure that the individual has connected with their primary care provider and/or specialist
• Ask about symptoms, concerns, and medications-coaching approach
• Is the plan working?
• Are they accessing the necessary community resources ?
• Is their caregiver showing up?
• Do they feel safe?
• Does the caregiver have questions?
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
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Coaching Approach
Coach the resident/resident representative through solving the issue themselves:
• Provide guidance, reassurance and encouragement
• Encourage them to access services and resources that have been discussed
• Empower them to master the management of their health
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
Providing Follow Up
• Ensure that the resident and their caregivers know this individual before discharge
Have a designated person in charge of follow up
• Formal hand-off of medical care
• Review of course of care at your facility
• Key medication/treatment changes
Provider at the Nursing Home
should also follow up with
the Community medical provider
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
F661 Discharge Summary
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Discharge Summary Inclusions
(i) A recapitulation (or concise summary) of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative
(iii).Reconciliation of all pre-discharge medications with the resident’s post discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services.
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
Against Medical Advice
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Post Discharge Process
• Determine formalized process
• Care Navigation
• Transition of Care model
• Other
• Communication
• Coordination with care team (full continuum)
• Collaboration with partners
• Documentation
• Monitor outcomes
• QAPI
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Summary - Facility Planning
Policies and Procedures
01Identify available services and contacts in your community
02Education
03
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Questions?
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References and Resources
• Centers for Medicare & Medicaid Services State Operations Manual, Appendix PP – Guidance to Surveyors for Long Term Care Facilities (Rev. 173, 11-22-17): https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
• Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.16. October 2018: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html
• Agency for Healthcare Research and Quality: Chartbook on Care Coordination. Transitions of Care: https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure1.html
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
References and Resources
• Medicaid.gov: Improving Care Transitions: https://www.medicaid.gov/medicaid/quality-of-care/improvement-initiatives/care-transitions/index.html
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.
Disclaimer
“This presentation provided is copyrighted information of Pathway Health. Please note the presentation date on the title page in relation to the need to verify any new updates and resources that were listed in this presentation. This presentation is intended to be informational. The information does not constitute either legal or professional consultation. This presentation is not to be sold or reused without written authorization of Pathway Health.”
This presentation is for general information purposes only. It does not represent legal advice nor relied upon as supporting documentation or advice with CMS or other regulatory entities. (C)Pathway Health Services, Inc. All Rights Reserved. Copy with Permission only.