Circle of Care
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Transcript of Circle of Care
Reduce preventable hospital readmissions Safe transition from SNF to home Provide lower cost, high quality alternative
to acute care setting Provide patient-centered care
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Part A (Hospital Insurance) Qualifying Hospital Stay – Inpatient hospital
stay of 3 consecutive midnights Doctors orders for skilled services Skilled care required daily Up to100 day episode of care
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Required for traditional Medicare Fee For Service under Part A
Exceptions:◦ Medicare Advantage (Part C)
Tufts, Fallon, Blue Cross Blue Shield, etc.◦ PACE-Program of All Inclusive Care for the Elderly◦ SCO (Dual Eligible)-Senior Care Options◦ MGH Waiver Program
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Part A (Hospital Insurance) Services provided under a plan of care
established & reviewed regularly by a physician
Require one or more of the following◦ Skilled nursing care less than 7 days/week◦ PT, OT or ST
Certified homebound by physician Up to 60 day episode of care; 30 day
window
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24 – hour-a-day care at home Meals delivered to home Homemaker Services Personal Care (bathing, dressing and using
the bathroom) when this is the only required care
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Communicate with Skilled Nursing Facility and PCP
Provides Consistent Care Givers Telemedicine – Early symptoms recognition
and monitoring
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Mismanagement of medications Moderate to severe functional impairment Inadequate patient/family education Lack of family safety net Comorbidities Patient reluctant to allow care givers in
home Failure to keep follow up appointments Poor diet, insulin management Substance abuse
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Discharge planning starts on admit date Communication with patient, family, PCP
and home health agency Care management meetings with patient,
nursing, therapy and case management Discharge meeting with home health care Family and Patient education PCP notification – medication, lab, pending
tests and any special needs Electronic medical records
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C.O.A.C. H.◦ Communicate Expectations◦ Organize goals◦ Assign coach◦ Continued review◦ Handoff homework
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Home Health Care Agency (HHCA) Case Manager◦ Reviews patient chart w/SNF Interdisciplinary
Team (IDT)◦ Attends Discharge Planning Meeting at SNF◦ Coordinates required services (Nursing, Therapy,
etc.) with IDTSNF Case Manager◦ Schedules Home evaluation◦ Orders DME◦ Provides education to family care givers
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Conducts follow up calls with patient/family (within 48 hours)◦ Seek feedback-How patient is succeeding at home◦ Follow up on patient concerns◦ Provide over the phone education◦ Assist in providing additional/services if needed◦ Readmit to facility within 30 days (3 day inpatient
hospitalization not required)
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Include home health care providers in the discharge process
Educate home health care work force on SNF rules of participation, clinical capabilities, positive patient outcomes
Create an image; the SNF is part of the continuum
Common names; Rehab, Short Stay, Post Acute, Transitional Care
Section 87 State Health Care Reform Law
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