Team Team Based Based

Admission Admission AssessmentAssessment

Cheryl Boldt R.N.Cheryl Boldt R.N.Senior Consultant Maun-Lemke, IncSenior Consultant Maun-Lemke, Inc

clboldt@attglobal.netclboldt@attglobal.netwww.clintmaun.comwww.clintmaun.com

1-800-356-2233 1-605-351-85471-800-356-2233 1-605-351-8547

Nursing Facility Action PlanNursing Facility Action Plan• Work with “language” of Hospital Discharge Work with “language” of Hospital Discharge

Planners and Physicians over timePlanners and Physicians over time• Work with “knowledge base” and Work with “knowledge base” and

“language” of Facility Staff“language” of Facility Staff• Team based admission assessmentTeam based admission assessment shortly shortly

after admission to establish realistic after admission to establish realistic Discharge Date and Destination and Discharge Date and Destination and ARTICULATE needsARTICULATE needs

• Ongoing Communication of Discharge Date Ongoing Communication of Discharge Date and Destination to resident, family, all staff and Destination to resident, family, all staff and MDand MD

• SAFELY TRANSITION the Resident to the SAFELY TRANSITION the Resident to the next level of care per the plan and Follow-Upnext level of care per the plan and Follow-Up

• Work on “Network Culture Change” to Work on “Network Culture Change” to achieve safe and well orchestrated transfersachieve safe and well orchestrated transfers

Work with “language” of Work with “language” of Physicians and Hospital Physicians and Hospital

Discharge Planners.Discharge Planners.

Hospital Discharge Hospital Discharge PlanningPlanning

ACUTE HOSPITALACUTE HOSPITAL• Example: You only need to go to the Example: You only need to go to the

Nursing Home for…1week, 2 weeksNursing Home for…1week, 2 weeks..• The Hospital Discharge Planner is The Hospital Discharge Planner is

trying to facilitate the resident leaving trying to facilitate the resident leaving the hospital and there are time the hospital and there are time constraintsconstraints

• A short time frame in the Nursing A short time frame in the Nursing Facility, while it may be unrealistic, Facility, while it may be unrealistic, “seems” to be more readily accepted by “seems” to be more readily accepted by residents and families at this point.residents and families at this point.

SUGGESTED SUGGESTED Language for Discharge Language for Discharge

PlannersPlanners““Each patient is unique and the time it Each patient is unique and the time it takes to recover varies”takes to recover varies”

““The _______Facility has a team of The _______Facility has a team of experts who will assist you in experts who will assist you in establishing a good treatment plan establishing a good treatment plan based on your condition and based on your condition and circumstances”circumstances”

““We want you to SAFELY TRANSITION We want you to SAFELY TRANSITION to your desired destination”to your desired destination”

“ “ It is understandable to want to be at It is understandable to want to be at home, and we know you want to do home, and we know you want to do well at home and prevent any further well at home and prevent any further hospitalizations.hospitalizations.

Work with “knowledge base” Work with “knowledge base” and “language” of all facility and “language” of all facility

staff.staff.

Work with “knowledge base” Work with “knowledge base” of all facility staff!of all facility staff!

• Knowledge of “the system” in regards Knowledge of “the system” in regards to various options for care and servicesto various options for care and services

• Knowledge regarding payment for care Knowledge regarding payment for care and services at the various provider and services at the various provider locationslocations

• Assure information shared between Assure information shared between agencies/organizations/facilities is agencies/organizations/facilities is shared with the front line…shared with the front line…

TRANSFER FORMSTRANSFER FORMSYA’LL COME SHIFT REPORTS YA’LL COME SHIFT REPORTS

ExampleExample“Language” of Nursing “Language” of Nursing

Facility StaffFacility Staff• ““Our team of experts have extensive experience Our team of experts have extensive experience

working with people who have been in the hospital”working with people who have been in the hospital”• You need the “appropriate LENGTH OF STAY for your You need the “appropriate LENGTH OF STAY for your

condition and circumstances to assure successcondition and circumstances to assure success• ““Discontinue” therapy instead of “DISCHARGE” from Discontinue” therapy instead of “DISCHARGE” from

therapy. therapy. • ““Transition you to rehabilitation nursing to assure Transition you to rehabilitation nursing to assure

you maintain the skill level you achieved in therapy you maintain the skill level you achieved in therapy (REHAB LOW RUG)(REHAB LOW RUG)

• We know you want to SAFELY TRANSITION to _______ We know you want to SAFELY TRANSITION to _______ and I see your planned discharge date is _________.and I see your planned discharge date is _________.

• We know you want to be successful when you go We know you want to be successful when you go home and avoid re-hospitalization.home and avoid re-hospitalization.

Team Based Admission Team Based Admission AssessmentAssessment

Team Based Admission Team Based Admission AssessmentAssessment

• Set aside a designated time daily (M-F)Set aside a designated time daily (M-F)• 1 hour max1 hour max• Social Services, Dietary, Recreation Therapy Social Services, Dietary, Recreation Therapy

ask their “questions”ask their “questions”• Nursing presents “identified” risksNursing presents “identified” risks• Therapy presents info to date and asks Therapy presents info to date and asks

remaining questionsremaining questions• Team establishes realistic LOS/ DATE of Team establishes realistic LOS/ DATE of

Discharge/ Destination with resident/ family Discharge/ Destination with resident/ family and is able to ARTICULATE needsand is able to ARTICULATE needs

• Team Communicates Discharge Destination Team Communicates Discharge Destination and DATEand DATE

• PILOT and go from there to “troubleshoot” PILOT and go from there to “troubleshoot” barriersbarriers

What we need to do betterWhat we need to do better• Not expect Therapy to be the only driver of length Not expect Therapy to be the only driver of length

of stay for Medicare A in a Skilled Nursing of stay for Medicare A in a Skilled Nursing Facility . Facility .

• Nursing needs to get more involved with skilled Nursing needs to get more involved with skilled assessment and care planning inclusive of assessment and care planning inclusive of teaching and trainingteaching and training

• Utilization of Rehab or Restorative Nursing at the Utilization of Rehab or Restorative Nursing at the end of the stay to establish resident’s ability to end of the stay to establish resident’s ability to maintain skillsmaintain skills

• ArticulateArticulate to residents and family about our to residents and family about our expertexpert opinion of what is needed to achieve a safe opinion of what is needed to achieve a safe transition. transition.

• Support skilled services with required Support skilled services with required documentation for Medicare/Insurancedocumentation for Medicare/Insurance

• Get the Home Care, A.L.F. or Independent Living Get the Home Care, A.L.F. or Independent Living Staff involved earlierStaff involved earlier

Master Discharge CalendarMaster Discharge Calendar

Ongoing Communication of Ongoing Communication of Discharge Date and Discharge Date and

Destination to family, resident, Destination to family, resident, MD, all staff.MD, all staff.

Communication of Discharge Communication of Discharge Date and Destination Date and Destination

• How to we reinforce and How to we reinforce and communicate the DDD to communicate the DDD to Family/Resident ongoing?Family/Resident ongoing?

• How does the front line know How does the front line know the DDD?the DDD?

• How does the MD become How does the MD become informed of the DDD so he/she informed of the DDD so he/she can support the plan and not can support the plan and not discharge too earlydischarge too early

Safely transition the resident to Safely transition the resident to the next level of care or location the next level of care or location per the plan – Then “follow-up”.per the plan – Then “follow-up”.

Example:Example:Safe Transition from SNF Safe Transition from SNF

“ “We wish to provide you with the We wish to provide you with the best possible program to assure your best possible program to assure your safe transition to the living situation safe transition to the living situation you have chosen. Our professional you have chosen. Our professional staff will provide the environment staff will provide the environment you need to assure a successful you need to assure a successful return home or successful transition return home or successful transition to a new or different living situation. to a new or different living situation. Making this move with confidence in Making this move with confidence in your new skills will decrease the your new skills will decrease the stress you may be feeling regarding stress you may be feeling regarding your current disability or illness.”your current disability or illness.”