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By: Stephanie Jackson  |  Type: Article  |  On: October 27, 2017

CMS’ Discharge Planning Proposed Rule and the IMPACT on Post-Acute Care Transitions

The IMPACT Act, which is still in the process of being implemented today, was an effort to standardize those assessments across all PAC providers, so that case managers and others would be able to compare apples to apples and make the best care decisions for their patients.

No one knows better than a case manager the importance of quality data to help facilitate a safe transition of care for our patients. Quality data includes accurate, relevant and current information about the patient AND the post-acute care entities. In September 2014, Congress passed the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. At the time, patient assessment data was standardized by provider type, but not across the different post-acute care (PAC) settings. So, a skilled nursing facility, a physical rehabilitation center, and other types of PAC facilities might have completely different sets of questions they asked during patient assessments, and different ways of recording that information. The IMPACT Act, which is still in the process of being implemented today, was an effort to standardize those assessments across all PAC providers, so that case managers and others would be able to compare apples to apples and make the best care decisions for their patients.

“In essence, the act seeks to standardize data elements used through various patient and resident assessment instruments by aligning certain data elements across instruments, to support our ability to measure and compare quality across the providers and settings of care,” said Patrick Conway, MD, MSc., CMS Acting Principal Deputy Administrator, and Deputy Administrator for Innovation and Quality, and CMS Chief Medical Officer, in a 2016 video from MLN Connects published on YouTube.1 “The act allows interoperability, which permits the seamless exchange of information across providers—not only PAC providers, but other providers who offer care to individuals as well. In the ideal state, important information would follow the patient, as services are delivered in hospitals and by physicians, long-term and PAC providers, and home- and community-based service providers. This will be a critical step towards coordinating care and proving Medicare beneficiary outcomes.” 

Certainly, the goals Conway mentioned are the same goals of case managers everywhere—to have a uniform way to measure and compare PAC providers in order to make the best possible decision for each patient based on his or her individual needs. But we’ve still got a ways to go.

In October 2015, just over a year after the introduction of the IMPACT act, CMS announced the Discharge Planning Proposed Rule, which would “revise the discharge planning requirements that hospitals, including long-term care hospitals and inpatient rehabilitation facilities, critical access hospitals, and home health agencies, must meet in order to participate in the Medicare and Medicaid programs,” according to CMS’ website.2 “The proposed changes would modernize the discharge planning requirements by: bringing them into closer alignment with current practice; helping to improve patient quality of care and outcomes; and reducing avoidable complications, adverse events, and readmissions.” Importantly, CMS says, the proposed rule would also, finally, “implement the discharge planning requirements” of the IMPACT Act.

Under the proposed rule, hospitals and critical access hospitals would be required to:

  • Develop a discharge plan within 24 hours of admission or registration;
  • Provide discharge instructions to patients who are discharged home (proposed for hospitals and critical access hospitals only);
  • Have a medication reconciliation process with the goal of improving patient safety by enhancing medication management (proposed for hospitals and critical access hospitals only);
  • For patients who are transferred to another facility, send specific medical information to the receiving facility; and
  • Establish a post-discharge follow-up process (proposed for hospitals and critical access hospitals only).

With already-heavy workloads, case managers are going to need sophisticated tools in order to be ready to meet these requirements when the rule takes full effect. For example, in order to develop a discharge plan within 24 hours as the proposed changes require, case managers will need to find a way to sift through information about hundreds of different PAC providers quickly and efficiently. Luckily, software solutions exist now that allow case managers and other hospital workers to do just that—a comprehensive database with contact and geographical information, quality scores, medical and non-medical resources, and corresponding financial information for a variety of PAC providers.

Another critical feature of such a database, when it comes to meeting the requirements of the new CMS proposed rule, is that both the clinical care team and the patient and family members can access the database to make sense of the choices available. That’s because the new rule has a lot more focus on taking into account the patient’s input in their own care. “The proposed rule emphasizes the importance of the patient’s goals and preferences during the discharge planning process. These improvements should better prepare patients and their caregivers to be active partners for their anticipated health and community support needs upon discharge from the hospital or post-acute care setting,” says the CMS website. “In addition, patients and their caregivers would be better prepared to select a high-quality post-acute care provider, since hospitals, critical access hospitals, and home health agencies would be required to use and share data, including data on quality and resource use measures. This results in the meaningful involvement of patients and their caregivers in the discharge planning process.”

Case managers are committed to providing the highest quality and most complete post-acute care information to our patients. We realize the importance of patient and family buy-in of the discharge plan and its direct impact on keeping the patients from being readmitted to the hospital, and I believe that most of my colleagues support the proposed rulings in the IMPACT Act to help make this a reality. We also know, however, that it’s really difficult to access current, clean PAC data (that we trust) in an efficient manner. We need a resource database that not only provides lists, qualifications and special offerings of post-acute care providers but offers quality scores to help assure the case manager is creating the best discharge plan. We have a ways to go, but I’m confident that this type of solution will blaze a new trail for our patients and care team members.

About Carelike

Carelike's extensive database of medical and non-medical transition care providers allows your discharge team to improve their efficiencies. Provider data is augmented with proprietary professional quality metrics as well as CMS scoring. Our technology provides ease of use standalone portals or EHR integration to help discharge teams select the best care providers. 

Organize your patient and family communication with our CareTrait technology. Comply with CMS initiatives including the proposed patient discharge IMPACT Act rule and significantly reduce the burden on this already over-stretched group of professionals. The solution greatly improves communication between discharge teams, patients and families and prioritizes preferred community-based services enabling the case manager to fulfill their responsibilities while improving care coordination. 

 

 

References:

1. https://www.youtube.com/watch?v=LQpGMg2-bhQ

2. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-10-29.html  

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By: Stephanie Jackson  |  Type: Blog  |  On: October 11, 2017

Fitting the pieces together: Why is choosing quality post-acute care so hard?

Have you ever tried putting together a 1,000-piece jigsaw puzzle with all the pieces facing upside-down? Picture this scene and you have some idea what it’s like to come up with a quality post-acute care plan for patients.

Have you ever tried putting together a 1,000-piece jigsaw puzzle with all the pieces facing upside-down? Do you think you could do it? How about if you have five other people at the table, jostling for space, elbowing one another, rearranging the pieces you had just organized, each with their own agenda and strategy for getting to the complete picture? And what if none of those people was talking to each other? Picture this scene and you have some idea what it’s like to come up with a quality post-acute care plan for patients.

When patients are admitted to the hospital, it can be scary for them and their loved ones. All they want is to get better. Dealing with a health crisis can be overwhelming, even before you add the pressures of thinking about what will happen after the patient leaves, who will pay for it, and what their quality of care will be like. Many patients and families can only focus on the moment of the acute health crisis.

According to a 2015 report, “Report to the Congress: Medicare Payment Policy,” from the Medicare Payment Advisory Commission,1 about three million Medicare beneficiaries are hospitalized for a serious condition and then discharged to a post-acute setting in the US each year. As case managers, we know that in addition to providing the immediate care each of those patients need, there are healthcare workers behind the scenes, gathering at the table to put the pieces of post-acute care and discharge together from the moment the patient walks through the door. Stakeholders include the case manager, the patient, his or her family, the entire care team, and even the payers. Due to the complexities of many discharges, sometimes it seems like each person involved has his own cluster of puzzle pieces and is trying to put the whole picture together without being able to look at what anyone else is working on.

Mary, a sweet, 70-year-old lady who was living independently before her stroke, wants to return home and live life the way it was prior to her event. Her sister Lisa wants her in a rehab facility close to where Lisa lives so she can visit and help out. Mary’s daughter Susan, who has two kids and a full-time job, is sick with worry about how the family will afford the care Mary needs. On the healthcare side, physicians are feeling pressure to discharge as quickly as possible to keep the “revolving door” open and empty the bed for the next patient who needs it; CMS is imposing limits on both how long Mary can stay and penalties if she is readmitted (often a result of being discharged too soon); and case managers are scrambling to find the post-acute care options that are amenable to everyone involved, but more importantly, offer the highest quality of care for Mary’s individual needs. In this tense situation, it’s easy to forget what the final image will look like—a tranquil scene where everything fits just right.

Oftentimes, it feels like there are just too many moving parts to keep track of. Post-acute care options are abundant: skilled nursing facilities, physical and occupational therapy, nurses to administer medications, equipment providers, home health care, and more. How does Mary’s case manager or family know which facilities are best for stroke recovery, which ones have the best doctors, the lowest readmission rates, and the best quality outcomes? How can anyone decide how all these disconnected pieces fit together?

For many years, the responsibility fell squarely on the shoulders of the case manager—it became his or her job to flip all the puzzle pieces over, separate and organize them, and direct everyone at the table to work towards a complete picture. This challenging task involved researching facilities for every individual patient, acting as a liaison between all stakeholders, and making decisions that meet everyone’s best interests.

FierceHealthcare reports that in September 2016, expert panelists at the California Associations of Physicians Group (CAPG) Colloquium recommended four steps healthcare teams can take2 to make this task more manageable:

  • Order an evaluation to explore the possibility of home health
  • When discussing next site of care, ask, “Why not home?” to ensure the topic is broached
  • Consider palliative care options, which may best be administered at home
  • Communicate closely during handoff to a post-acute care facility (or with home caregivers) for high-risk patients

To take these and other steps in the right direction, healthcare teams need the right tools and data to make the best decisions. A July 2016 article in Hospital & Health Networks, titled “Why Post-Acute Care Partners Are Critical to Hospitals' Future,”3 notes that hospital executives “lack the formal mechanisms that might enable direct control of post-acute care, so they must establish relationships, processes and infrastructure to achieve coordination and control with trusted post-acute care partners.”

Fortunately, recent technology has provided the processes and infrastructure required, making the task of choosing post-acute care more manageable. What is needed is a robust database that both the clinical care team and the patient and family members can access to make sense of the choices available. Such a comprehensive database—with contact and geographical information, quality scores, medical and non-medical resources, and corresponding financial information—is the only way to get everyone working together to build the complete picture.

Sometimes it can be hard to remember that everyone involved is building the same puzzle and working to the same end goal—the best possible care for the patient. With the right tools, together we can create a finished picture that we can be proud of, with pieces that interlock in precisely the right way.

 

About Carelike

Carelike's extensive database of medical and non-medical transition care providers allows your discharge team to improve their efficiencies. Provider data is augmented with proprietary professional quality metrics as well as CMS scoring. Our technology provides ease of use standalone portals or EHR integration to help discharge teams select the best care providers. 

Organize your patient and family communication with our CareTrait technology. Comply with CMS initiatives including the proposed patient discharge IMPACT Act rule and significantly reduce the burden on this already over-stretched group of professionals. The solution greatly improves communication between discharge teams, patients and families and prioritizes preferred community-based services enabling the case manager to fulfill their responsibilities while improving care coordination. 

 

 

References:

1. http://www.medpac.gov/docs/default-source/reports/chapter-7-medicare-s-post-acute-care-trends-and-ways-to-rationalize-payments-march-2015-report-.pdf?sfvrsn

2. http://www.fiercehealthcare.com/healthcare/send-patients-to-appropriate-post-acute-care-to-improve-outcomes

3. http://www.hhnmag.com/articles/7421-why-post-acute-care-partners-are-critical-to-hospitals-future

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By: Stephanie Jackson  |  Type: ArticleBlog  |  On: October 02, 2017

It’s Not All About Reducing Length of Stay

If I’ve heard it once, I’ve heard it 100 times (a day), “How can we reduce the length of stay for our patients?” This question is increasingly becoming the Achilles’ Heel of a case manager’s discharge plan.

If I’ve heard it once, I’ve heard it 100 times (a day), “How can we reduce the length of stay for our patients?” This question is increasingly becoming the Achilles’ Heel of a case manager’s discharge plan. That, in combination with the pressures to reduce potentially avoidable readmissions, keeps case managers up at night. I believe the length of stay in a hospital is heavily correlated to a readmission. A premature discharge is just as risky as an admission that drags on unnecessarily, and I’ve always challenged hospital administrators on their constant pressure to discharge my patients as quickly as possible. Oftentimes, this strategy is counterproductive and results in patients being pushed out of the hospital too soon, causing them to end up right back in the emergency room.

Nationally, according to the Centers for Medicare and Medicaid Services (CMS), the average length of a hospital stay decreased by a significant 44 percent from nine days in 1990 to five days in 2014.[1] Now don’t misunderstand, we all agree the preference for patients and their families is to return to life outside the hospital as soon as possible. The longer the patient remains in the hospital, the greater the likelihood of an adverse event –  hospital acquired infections, medication errors, unnecessary and costly tests and procedures, falls, etc. That being said, we need to focus less on reducing length of stay and more on optimizing the treatment plans while the patient is hospitalized.

Granted, it’s hard to dispute the high costs of an extra day or two in the hospital. In 2014, the average cost per inpatient day was $2,346 at non-profit hospitals and $1,798 at for-profit hospitals.[2] However, the costs of a readmission are even higher. This is true, not only in terms of dollars, but from the patient’s perspective as well. A whole new set of tests are run, new medications with new side effects are prescribed, a more complicated discharge planning process occurs, and the emotional roller coaster associated with a readmission is stressful for everyone.  

A recent study out of New York[3] examined 12,341 admissions from 79 physicians to determine how a shorter length of stay impacts patient outcomes. The results were compelling and found that patient admissions from “short length of stay physicians” were associated with a significantly higher “30-day mortality”. Clearly, a premature discharge from the hospital can be dangerous to your health.

So, how do we optimize length of stay to achieve the best outcomes? Once again, we look to the case manager to coordinate the plan. The case manager is the quarterback. She must remain in constant communication with the patient’s entire care team from the minute the patient is admitted. She must listen carefully to the physicians’ proposed treatment plans, including the expected timing of the discharge and alert the team to potential barriers, especially the often overlooked impact of social determinants that can negatively influence the patient’s transition to the next level of care. Oftentimes, the case manager concludes that one or two additional days in the hospital will greatly lessen the chance of a readmission.

Of critical importance to the case manager’s successful care plan is access to the highest quality post-acute services available to the patient based on his personal situation: insurance coverage, financial means, family support, living arrangements, ability to resume his routine activities of daily living, etc. Often, the patient can safely return home if he has the support he needs.

One of my many memorable patients, Frieda, was a 90-year-old, highly independent woman who had a history of Congestive Heart Failure (CHF). She was admitted to the hospital with CHF exacerbation. We implanted a pacemaker, diuresed her through a medication adjustment, increased her oxygen requirements and educated her on her diet and salt intake. She was ready to go home. The medical team and her family, however, didn’t agree with Frieda’s plan. I remember her taking my hands into her own and pleading with me to help her return home. I convinced the team to postpone her discharge for a day and a half (despite exceeding the strict length of stay guidelines) to give me the opportunity to create a safe plan for my patient. Guess what? Frieda returned home, albeit with the support of many resources.

We need to constantly advocate for our patients, and now we can do just that, with tools and technology that didn’t exist a decade ago. I believe an optimal length of stay can be achieved with not only a carefully executed plan of care, but access to the latest technology and comprehensive medical and ancillary resources.


About Carelike

Carelike's extensive database of medical and non-medical transition care providers allows your discharge team to improve their efficiencies. Provider data is augmented with proprietary professional quality metrics as well as CMS scoring. Our technology provides ease of use standalone portals or EHR integration to help discharge teams select the best care providers. 

Organize your patient and family communication with our CareTrait technology. Comply with CMS initiatives including the proposed patient discharge IMPACT Act rule and significantly reduce the burden on this already over-stretched group of professionals. The solution greatly improves communication between discharge teams, patients and families and prioritizes preferred community-based services enabling the case manager to fulfill their responsibilities while improving care coordination. 


 

[3] J Gen Intern Med. 2015 Jun;30(6):712-8. doi: 10.1007/s11606-014-3155-8. Epub 2015 Jan 24. Increased Risk of Mortality among Patients Cared for by Physicians with Short Length-of-Stay Tendencies.

 

Read in about 5 minutes
By: Carelike Team  |  Type: Article  |  On: September 19, 2017

So, What If It Was YOUR Mom Who Needed Care?

Throughout my years practicing as an RN Case Manager, I can attest to the often heart-wrenching challenges of families trying desperately to find the best care for their loved ones during unexpected, tumultuous health circumstances.

Throughout my years practicing as an RN Case Manager, I can attest to the often heart-wrenching challenges of families trying desperately to find the best care for their loved ones during unexpected, tumultuous health circumstances. Picture the frequent scenario where Mom is living alone, managing her life quite nicely with the support of family and friends, and suddenly she experiences an adverse health event – a fall, a new diagnosis, or a complication of her chronic illness that lands her in the hospital.

The family rallies its troops to coordinate plans to provide the support and strength needed to allow Mom to return to her prior level of independence at discharge. They rely on the resources of the hospital to help them craft the discharge plan. Namely, they look to the Case Manager for information on where to go, what to do and when to start the process. Every day, family members ask, “Can you please just let me know the best resources available for my mom to help her safely return home after discharge?” You’d think the answer would be, “Sure, together let’s research the best options based on readily available, accurate qualitative and quantitative data.” Unfortunately, most of us can’t say that. The data simply doesn’t exist and where it does, it’s stored in multiple, disparate siloes making it impossible to manage across a challenging patient census.

We are a data driven society. We research nearly every purchase, large or small before making a buying decision. We pour through Google searches, Consumer Reports, Amazon, etc., etc. to identify the best value for our money. We wouldn’t consider purchasing a car, a bike or even a skateboard without understanding the pros and cons of the item. Why then are we willing to accept the lack of performance, outcome and cost data on such personal, life-changing decisions as selecting the highest-quality care providers for ourselves and our loved ones?

 

Work In Progress (A Common Phrase in Healthcare)

We’re certainly making progress in several areas along the healthcare spectrum; hospitals and physicians are increasingly being ranked by organizations like the Centers for Medicare and Medicaid Services’ (CMS) Hospital Compare and Physician Compare websites and third-party reviewers like Healthgrades, ZocDocs, WebMD and others. Where we lack clean, accurate and reliable data is in the post-acute care arena - home health and private duty agencies, durable medical equipment companies, infusion, dialysis and wound care centers, assisted living facilities, etc. This integral part of the care continuum has largely been ignored despite its significant impact on quality of life as well as the sheer volume of the population requiring care. According to the U.S. Department of Health & Human Services, 70% of people turning 65 will utilize some form of long-term care during their lives whether skilled or custodial care, facility or home based, or community support services.

Post-acute care data decays rapidly, rendering it nearly useless to those of us who rely on current and complete information to execute optimal care plans for our patients. This data deficiency has historically resulted from a lack of standardization of healthcare data including cost and quality metrics on services outside the four walls of the hospital. The post-acute data issue is further exacerbated by high levels of staff turnover within these organizations, antiquated or absent technology and negligible operating margins with little wiggle room to invest in analytics. However, in the fee-for-service world, a hospital’s accountability for the patient ends at discharge, so the lack of post-acute data, while frustrating, doesn’t impact the hospital’s bottom line. As long as the Case Manager documents a safe transition plan to the next level of care, there will be no penalties imposed if the patient returns to the hospital due to a complication or discharge failure.

 

The New Post-Acute Paradigm –  It’s All About Outcomes

The advent of value-based care, including CMS’ Hospital Readmissions Reduction Program, Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medicare Bundled Payments for Care Improvement Initiative (BPCI) and other government and private payer value-based models, is turning the industry on its head. Providers along the entire care continuum must collaborate with each other and share data to help improve care transitions, care delivery, patient outcomes and the patient experience or face stiff financial penalties, patient dissatisfaction, provider disengagement and a breakdown of the system.

The aforementioned initiatives represent only the tip of the iceberg for the healthcare industry in terms of new regulations, new models of care and the resulting new data requirements to validate program effectiveness. I’m hopeful the proposed changes to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) will soon be a reality. This act, designed to improve transparency and patient experience during the discharge planning process, will require hospitals and post-acute care providers “to use data on both quality and resource use measures to assist patients during the discharge planning process, while taking into account the patient’s goals of care and treatment preferences”. 

That all being said, I’m confident that every hospital, payer or other risk-bearing entity, family member, and patient would agree that a unified, comprehensive database of current medical and non-medical services and the corresponding financial arrangements and quality indicators is a necessary component to achieving the best medical, behavioral and social outcomes for those we serve. Since I left my role as a hospital discharge planner in 2012, a wide variety of new applications and databases have emerged as potential solutions to this dilemma.

In fact, it is now possible to imagine a world where Mom’s transitional healthcare needs are carefully and deliberately matched to providers through real-world, evidence-based data.

Can your organization provide this needed service for your patients?

Please feel free and reach out to me directly to share your own experience in optimizing care within the realities of healthcare today. I’d love to hear how your organization is helping to accomplish this lofty goal while traversing the rocky road to value-based care.

 

Contact Carelike to help improve the efficiency of discharge care.

 

For more information about Carelike, please contact Katy Weisbrodt:

O: (404) 250-8376   |   C: (770) 851-8653   |   kweisbrodt@carelike.com   |   www.carelike.com/hospitals


About Carelike

Carelike's extensive database of medical and non-medical transition care providers allows your discharge team to improve their efficiencies. Provider data is augmented with proprietary professional quality metrics as well as CMS scoring. Our technology provides ease of use standalone portals or EHR integration to help discharge teams select the best care providers. 

 

Organize your patient and family communication with our CareTrait technology. Comply with CMS initiatives including the proposed patient discharge IMPACT Act rule and significantly reduce the burden on this already over-stretched group of professionals. The solution greatly improves communication between discharge teams, patients and families and prioritizes preferred community-based services enabling the case manager to fulfill their responsibilities while improving care coordination. 

 

 

Read in about 6 minutes
By: Carelike Team  |  Type: Article  |  On: September 15, 2017

Wait, What? He’s Being Discharged Tomorrow?

These words elicit a wide range of emotions based on whom they’re being spoken to and the preparedness of the responsible parties including the discharge planner, the patient’s family and of course, the patient himself. The discharge planner silently chuckles with doubt as she sits in the multidisciplinary rounds

These words elicit a wide range of emotions based on whom they’re being spoken to and the preparedness of the responsible parties including the discharge planner, the patient’s family and of course, the patient himself. The discharge planner silently chuckles with doubt as she sits in the multidisciplinary rounds and hears these words from the powers that be, knowing full-well the ensuing challenges of a successful discharge within 24 hours. The family members nod in cautious agreement while reeling with fear of the unknown. Who will care for their loved one? What services will he need? What costs will be incurred? The patient is either excited, clueless or filled with trepidation. 


Those of us who share the title of Case Manager, Care Manager, Discharge Planner, etc. and are licensed as a Registered Nurse or Social Worker are part of a club that’s small but elite, powerful yet not always respected, and resourceful but often lacking necessary resources. We’d all agree there are basically three types of discharges: Piece of Cake, Bit of a Challenge, and the Total Train Wreck. While we all love those Piece of Cake patients with the perfect, loving, caring family and a simple medication cocktail ordered at discharge, we also know that the Challenge and Train Wreck discharges are imminent and will require time, energy and patience. 

And, we’re working in an environment riddled with uncertainty, constantly changing regulations and more “disruptive” new government and private payer initiatives than ever before including the “volume to value” conundrum which instructs us to prevent inappropriate admissions and readmissions while at the same time understanding that “heads on beds” yields money and frankly our job security. The Centers for Medicare and Medicaid Services’ (CMS) 30-day readmission penalties are at the forefront of hospital executives’ agendas due to the significant financial penalties they can potentially impose on a hospital.


Furthermore, as a result of the evolving trend towards ambulatory care, the vast majority of hospital inpatient admissions are those with very clinically complex conditions. Yet, hospitals continue to carefully monitor lengths of stay to optimize reimbursement which further complicates the discharge process and shortens the amount of time the case manager has to create a safe and efficient transition to the next level of care whether that be to a long-term acute care facility, a skilled nursing facility, or home with some level of professional or custodial support.

To further support the radical changes in the industry, CMS is proposing amendments to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) which defines initiatives and measures to improve the quality of post-acute care. According to CMS, “The IMPACT Act requires hospitals, critical access hospitals, and certain post-acute care providers to use data on both quality and resource use measures to assist patients during the discharge planning process, while taking into account the patient’s goals of care and treatment preferences.” Participation in the Medicare and Medicaid programs will be dependent on aligning with these new requirements. 

So, where do we go from here? A quick “Discharge 101” lesson will confirm the challenges those of us in the field face every day and should also help those unfamiliar with the process understand the complexities and roadblocks we face in facilitating transitions along the care continuum. 

The formula for a successful discharge plan:

  1. Is initiated immediately upon admission through a comprehensive assessment of the patient’s needs including family support, living arrangements, equipment needs to help with activities of daily living (ADLs), financial considerations and insurance coverage
  2. Considers not only the patient’s medical and emotional needs but also the social determinants that impact the discharge in ways that are often grossly underestimated
  3. Has buy-in from the patient, family and medical team

Once the plan is established, it’s time to execute the various action items. This is where the “fun” comes in for the discharge planner. Imagine Freddie, our “Bit of a Challenge” patient who was admitted on Monday, and according to the medical team is ready for discharge Friday. Freddie is a 91 year old, feisty gentleman with a history of COPD, degenerative disc disease and diabetes. To top it off, Freddie lives alone in a two-story house, has family who occasionally checks on him, relies on the city bus system for transportation and enjoys his bourbon.  The case manager is tasked with taking each of these considerations into account and formulating a plan that will enable a safe discharge and prevent a readmission. (And, by the way, we are held accountable for inappropriate readmissions and are measured against this metric in our reviews…)


Freddie will need the following minimal level of services to successfully transition out of the hospital:

  • Home Health Care: RN to monitor for medication adherence, check vitals, etc.; a dietician to advise on his food intake to manage the diabetes and coach him on the effects of alcohol on his blood sugar; and PT/OT to perform a home safety evaluation and educate him on the importance of a safe exercise routine
  • Durable Medical Equipment: Oxygen due to his worsening COPD; a wheeled walker; diabetic supplies
  • Home Care (Private Duty): Nurse’s aide to assist Freddie with bathing, cooking, shopping, finances
  • Transportation and other ancillary support services: Referral to the Area Agency on Aging

Keep in mind that Freddie isn’t even a Train Wreck patient, and he’s only one of 15-20 plus patients on the case manager’s census needing to be followed throughout the admission. 

So… it’s no surprise that the discharge is a lengthy, complicated and often stressful process and is typically left to the case manager to coordinate all of these care interventions and services. Unfortunately, while we possess strong critical thinking skills and are multitasking masters, we lack the tools necessary to effectively perform our responsibilities. 

If you speak with any care manager, you’ll find that with all the increased legislation, measurement and oversight, their responsibilities have drastically increased – while there are still only so many hours in a day. What many people may not know is there is hope on the horizon. There are now innovative software and database applications that have the power to streamline and organize information – helping you to identify the most appropriate next level of care with just a few clicks rather than spending hours of research and coordination. As you can tell, I’m very passionate about the critical role that care managers play in the care continuum. Please feel free and reach out to me directly if you’d like any additional information or if I can help you in any way. In the meantime, here’s hoping for more Pieces of Cake, and fewer Train Wrecks!
 

How accurate and up-to-date is your organization’s post-acute and community care data? 
For more information about Carelike, please contact Katy Weisbrodt:
O: (404) 250-8376   |   C: (770) 851-8653   |   kweisbrodt@carelike.com   |   www.carelike.com/hospitals  

About  Carelike
Carelike provides a national database consisting of more than 370,000 post-acute and community care providers that allows the case manager to more efficiently locate all the necessary providers required for a safe discharge and takes into account the patient’s medical needs, social needs, and financial constraints. 
In addition, our CareMatchTM technology will help hospital case managers comply with CMS initiatives including the proposed patient discharge IMPACT Act rule which significantly reduces the burden on this already over-stretched group of professionals. The solution greatly improves communication between the hospital and community-based services and enables the case manager to fulfill her responsibilities and coordinate care with each of the various stakeholders involved in the discharge.

Read in 6 minutes
By: Stephanie Jackson  |  Type: Blog  |  On: December 22, 2016

5 New Year’s Resolutions for care professionals

There are several New Year's resolutions that you could try to achieve that specifically apply to your work as a caregiver.

Believe it or not, 2016 is coming to a close, which means that a lot of people are thinking about New Year's resolutions. There are several New Year's resolutions that you could try to achieve that specifically apply to your work as a caregiver.

A new year is always a fresh start. Consider some of these New Year's resolutions for caregiver in order to have a happy and healthy 2017 for both you and your patients.

1. Take more time for yourself: As a caregiver, you often have a lot of responsibilities both at work and at home. And, more often than not, it can seem like you are burning the candle at both ends at times. However, your career as a caregiver is all about finding the right work-life balance. After all, if you are completely burnt out at work, you aren't going to be in the right mindset to properly care for your patients. Be sure that you take time off when you need it, find room to exercise and relax, and keep those extra-long days to a minimum. 

2. Get organized: With so many patients, medication schedules and updates to keep track of, caregivers need to take steps to be more organized. Fortunately, there are a lot of tech solutions that can help you accomplish this. Also be sure to document all of your patients' papers and files in an online forum so that they are easy to find. Some time management tools include CareZone, Evernote and Personal Caregiver, to name a few.

 

There are plenty of great New Year's Resolutions for care professionals this year.

There are plenty of great New Year's resolutions for care professionals this year.

3. Learn how to delegate and say 'no' when you need to: Caregivers by nature want to make sure they are doing everything they can for their patients. However, it's simply impossible to meet everyone's needs 100 percent of the time. To prevent burnout and make sure your patients are properly cared for, you will need to learn how to say no when you simply don't have the time and to lean on family caregivers and friends of patients when you can't be there in person.

4. Start doing your research: With so many therapies and treatments getting more advanced by the minute, the possibilities for better care are endless. When have some down time, begin reading studies and publications about caregiving so that you are staying on top of the best cutting-edge treatments. You could also take the time to learn about healthcare plans and reforms so that you are better equipped to answer common questions from your patients about coverage and costs.

5. A renewed focus on nutrition and exercise for your patients: Seniors need daily exercise and nutrients in order to live the best quality of life. However, this is far too often swept under the rug in most care plans today. While you are documenting your patients' care plans, be sure to also include information about diet and exercise so that you have a holistic care plan in place for all of your patients heading into 2017.

If you are unsure about what your New Year's resolution should be this year, consider one of these suggestions to get 2017 off to a good start. 

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By: Stephanie Jackson  |  Type: Article  |  On: November 28, 2016

Coordinating home healthcare schedules with patient family members

The field of caregiving is growing and becoming much more reliant on technology to keep up with the demands of modern healthcare.

Caregiving is a task that requires a lot of patience and understanding. In addition to having empathy for those who need your medical care, you must find ways to make caregiving management less stressful and more meaningful for both you and your patients.

Many of your patients rely on family members to help them complete daily tasks, especially if they struggle with cognitive issues like Alzheimer's disease or physical disabilities. Everything from medication instructions to appointment scheduling must be communicated with family members and other loved ones to ensure your patients are finding the right balance and staying as healthy as possible.

That's why coordinating schedules with patient family members is so important. It helps you communicate better with the people who need your services the most, and it also makes your job a little easier as well. Fortunately, the field of caregiving is growing and becoming much more reliant on technology to keep up with the demands of modern caregiving.

If you're a healthcare provider looking for better ways to coordinate schedules with patient family members, read below for some sound advice on how to get started.

 

There are several caregiving apps that can help better manage your time with patients and their families.

There are several caregiving apps that can help better manage your time with patients and their families.

1. Talk about your schedules from the very beginning: It's easy to get overwhelmed with your work as a caregiver, so you'll need to set boundaries and schedules with new patients and their families from the very beginning. Let them know when you will be available for work and when certain hours and days are off-limits. Being a caregiver means you can likely balance your own schedule and do amazing things for your patients. However, job demands can be challenging in this field, so it's important to schedule time for yourself as well.

2. Make a care calendar for patient family members: With so many appointments, medications and treatments to keep track of with each patient, care calendars are a must. Just like you, patient family members have careers, schedules, relationships and kids to think about in addition to their loved one who needs care. Having a care calendar lays out all of the information your patient needs upfront so that both parties can keep track of medications, doctor's visits, physical therapy sessions and other treatments needed to stay healthy.

3. Try out caregiving apps: Smartphones and other remote devices have become a huge asset for caregivers who want to balance schedules, especially with patients and their family members. According to Provider magazine, there are several reputable apps to choose from that can help you balance your activities directly from your phone or tablet, and some even link to social media sites and online calendars to make life even easier for all parties involved. What's more, many of these apps are available for free through the iOS and Android stores. Some of these include Balance, CareZone, Balance and Care/Mind. If you already carry around a smartphone for personal use, try downloading one of these apps to see if it works for you and your busy lifestyle.

Balancing your time as a caregiver can get tricky, especially with so many people to care for. However, by following these tips, you can worry less about scheduling and focus on what matters most: your patients and their families.

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By: Stephanie Jackson  |  Type: Press Release  |  On: November 15, 2016

Carelike, LLC. leads change in senior care referral industry

Carelike differentiates from its competitors by giving care seekers access and transparency to all providers in their area, not just those who pay for a profile. Carelike displays all available information, truly giving families the power of choice and the ability to make informed decisions.

Carelike, LLC. leads change in senior care referral industry

Media contact:
Stephanie F. Jackson
Carelike, LLC.
Tele: (404) 250-8370

ATLANTA, GA. (November 15, 2016) -- As many Americans (especially baby boomers) are discovering, finding the perfect care service for a senior loved one is challenging. Per data from a 2015 AARP report, approximately 43.5 million adults provided unpaid elder care, mainly to relatives. This number only stands to grow as baby boomers age, and Carelike has come up with a solution.

With most senior-placement companies, care seekers use online or call-in services to find an assisted living community or home health aide for their loved one. However, they only get information from a small, select number of providers who have a contract to be listed on that referral company's website. This means care seekers miss out on many providers who might more closely fit their needs, have more esteemed credentials or elicited better patient reviews.

The senior care referral industry has been around for years, and so has Carelike (previously SNAPforSeniors). The organization is well-connected and has the experience and expertise required to drive a much-needed change to the industry. Their business model has always put the care-seeker first. Everyone who is a licensed senior care professional - not just those who "pay to play" - shows up in Carelike's comprehensive database of providers. This is because Carelike pulls from 400 different sources to gather data on senior and post-acute care providers. The organization then goes to great lengths to clean, filter and augment the data to give care seekers the most up-to-date and accurate picture of each provider.

This methodology has made Carelike the preferred partner for organizations who help consumers find care, which include renowned health organizations, health insurance companies, care management companies, EAPs and patient advocacy groups, including the Alzheimer's Association.

If you haven't heard of Carelike, it may be because the company has always worked behind the scenes providing well-known, reputable organizations with data. Now that this company aims to appeal to consumer care seekers, Carelike will share providers' information with not only organizations who license the data but with family members looking for senior services through their new consumer search site.

Carelike is the only online senior listing company that provides that type of exposure for providers - to both consumers and professional care-seekers at organizations who license the data. Meanwhile, Carelike differentiates from its competitors by giving care seekers access and transparency to all providers in their area, not just those who pay for a profile. Carelike displays all available information, truly giving families the power of choice and the ability to make informed decisions. Discover the possibilities for yourself at CareLike.com.

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By: Carelike Team  |  Type: Article  |  On: September 13, 2016

How to become a home health aide

Caregiver jobs offer a gateway to an exciting and rewarding career path that other occupations simply can't offer.

Caregiver jobs offer a gateway to an exciting and rewarding career path that other occupations simply can't offer. However, the idea of all the studying, classwork and experience required to become a nurse practitioner or doctor often dissuades compassionate people from pursuing these careers. Fortunately, there's a way you can help others in no time at all - by becoming a home health aide.

As U.S. News and World Report explained, home health aides perform a combination of nursing duties and housework in an effort to make living at home easier for clients. For instance, they might one day help wipe up a spill in a senior's kitchen that the individual can't bend down and clean on his or her own. The next afternoon could be spent bathing patients and attending to wounds.

Andrea Devoti of the National Association for Home Care & Hospice told USN that home health aides have a unique and profound impact on clients.

"Many of our patients will think of their [home care aide] as the nurse that really cured them because he or she helped them do the things they needed to do to get well," she said.

According to the U.S. Bureau of Labor Statistics, demand for this job is growing, and home health aides make an average hourly wage of $10.54. If you're looking for a way to make money doing exactly what you love, you might consider pursuing a career as a home health aide. Learn how to get started:

Determine if this career path is right for you
If you're reading this article, you no doubt have a passion for helping others. However, there is more to the home health aide job than providing care. It's important to understand all responsibilities to determine whether this career is the right for for you.

According to the BLS, home health aides may help clients with daily living tasks like bathing and dressing, organize and plan their appointments, check vital signs, perform housekeeping, encourage socialization and go grocery shopping.

 

CPR training group.

Home health aides may need to undergo CPR training to become certified.

Receive training
If those duties seem like tasks you'd enjoy, then the next step involves training. Formal education is not a requirement for this position, but you will need training from a qualified agency, which will teach you how to check vital signs, nutrition basics and first aid, among other relevant lessons. Afterwards, you'll have to pass a competency test in order to receive certification.

Apply for jobs
Now, it's time to start your job hunt! You'll likely apply for a home health agency that will then connect you with clients. This way, you can receive guaranteed hours and employee benefits as well as support for caring for clients.

To make sure you land the interview, Entrepreneur advised making sure you meet most of the qualifications before applying. Additionally, adjust your resume to better demonstrate how your skills make you an ideal candidate for a particular job. 

What are you waiting for? If a career as a home health aide seems like the right fit for you, get started on your journey today.

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By: Carelike Team  |  Type: Article  |  On: September 01, 2016

Stay safe as a home health care worker

A general sense of caution is vital for home health workers considering you have limited control over the work environment.

Homes are often regarded as safe havens. However, if you're working in the home health field, it's important to avoid letting your guard down even if the house's walls are lined with embroidered pictures of flower fields. While you certainly shouldn't fear your clients, a general sense of caution is vital considering you have limited control over the work environment. Here are a few tips to stay safe on the job:

Beware of dog
Even the most experienced animal experts are at risk for injury. Just consider the Bengal tiger who attacked Roy Horn of Siegfried & Roy in 2003. The men had put on shows with these animals 2,000 times without incident before one cat inexplicably mauled Roy, according to the Today show.

While it's unlikely you'll encounter a tiger while working in home health jobs, pets can pose risks, too. Survey data cited in the book "Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment)" found that 17 percent of home health care workers have dealt with aggressive pets on the job. The Idaho Department of Health and Welfare advised those in this field to not touch pets. In fact, you might benefit from requesting the client put the animal in a cage or separate room during your visit.

 

Beagle sitting in kennel.

As tempting as it may be, avoiding touching clients' pets to remain safe.

Practice caution with clients
While your job is to help clients with daily living activities and provide care, you have to look out for your own well-being, too. According to the Occupational Health and Safety Administration, health care workers are at a higher risk for workplace violence than other occupations, much of which is due to violent clients. Individuals you work with are unwell in some shape or form, and their condition can make them aggressive. For instance, a devastating prognosis or certain medications can prompt people to be combative.

This won't be the case with every client you encounter, but if an incident does occur, use it as an opportunity to evaluate cause and risk factors. Adjust your practices to protect yourself, or speak with your employer about working with a colleague on certain jobs to create a safer environment.

"Always bring along non-latex disposable gloves and hand sanitizer."

Keep it clean
Your own home might be spick and span, but there's no telling what conditions will be like in your clients' houses. According to the National Institute for Occupational Safety and Health, unsanitary spaces exasperate the spread disease and infections and can cause medical supplies to become contaminated. Some may even put home health workers in the midsts of bed bugs or mites.

If this is the case for you, always bring along non-latex disposable gloves and hand sanitizer. Additionally, limit what supplies you take into the home, as this will expose less equipment to potential contamination. Finally, watch where you place your belongings, like a purse or backpack. Instead of setting them down on the carpet or upholstered furniture, which are more likely to harbor germs, set them on a table or keep them in the car.

Handle with care
Data from the Bureau of Labor Statistics found that nursing assistants are among the top occupations for incurring musculoskeletal injuries. Lifting patients is a major contributor to this issue. It's important for home health workers to practice appropriate techniques when moving clients.

This can be challenging in the home health field considering these workers often go to jobs alone and client homes don't always have lifting equipment. In this case, you should assess the patient's risk for falls and keep an open line of communication with your employer about the situation. Together, you and the agency you work for can come up with a plan to keep both you and the client safe from injury.

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