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Referral!Guide!
5 Important Steps to Improving Care for Older Adults Guide to Senior Care Options & Patient Care Assisted / Alzheimer’s – Home Healthcare – Hospice – Home Care Senior Living - Skilled Nursing & Rehabilitation – Rehabilitation MOBILE'AND'DIGITAL'AVALIABLE''
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CONTENTS
Volume 1 Issue 2 Illinois
More than half of adults 65 and older have at least three chronic conditions, such as heart disease, diabetes, arthritis, high blood pressure, or Alzheimer’s disease.
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Levels of Care HOME CARE 10 Allowing a non-medical home care assistant (caregiver) provide transportation, meals, and daily needs.
ALZHEIMER’S 6 Programs and assistance designed with those with memory loss; some communities will provide specially trained security measures to prevent residents from wandering.
HOSPICE 12 In home of facility end of life care for the terminally ill with pain management, comfort, and emotional support being the primary mission for the family.
ASSISTED LIVING HOME Along with assistance, residents enjoy daily activities, some level of healthcare services, and daily meals.
SKILLED NURSING & REHAB 17 Licensed and equipped to provide healthcare which meets the needs of more extensive physical issues, and assist residents to regain mobility.
HEALTHCARE 7 Allowing patients to remain at home eliminating travel for treatment; alternative to hospital stay or a skilled nursing facility.
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• Caregiver Support • Educational Programs
in Alzheimer’s and Dementia Care Caring for a loved one with memory loss can be a full time
job, and selecting the right health care provider can be overwhelming. At Arden Courts, we know, we understand and we can help.SM Memory care is all we do from the specialized programming and trained staff to the homelike design and family education and support. Your job is personal and ours is professional. But together we can give your loved one all the attention and care they deserve. Schedule a tour of our innovative memory care community and receive a complimentary dementia resource kit.
Elk Grove Glen Ellyn 847.534.8815 630.469.5500
Northbrook South Holland 847.795.9000 708.895.1600
Geneva Hazel Crest 630.262.3900 708.799.7099
Palos Heights 708.361.8070
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HOME HEALTHCARE !
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HOME CARE !
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HOME CARE !
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The Complete Continuum of Care
Free daily telephone reassurance calls
Compassionate non-medical in-home care
Save up to 65% with Free ABC Rx cards
Escorted tours of assisted living communities
Always Best Care Senior Services ®
Non-medical in-home care • Assisted living services Dedicated to exceeding your expectations ... always
Call one of our Chicago locations today!
Chicago North Chicago West Chicago Southwest
(847) 730-5930 (855) 761-9755 (708) 320-8222
Independently owned and operated offices throughout the United States
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Important Steps to Improving Care for Older Adults Principles to Help Clinicians Manage the Care of Older Adults with 3 or More Health Conditions Following Standard Clinical Guidelines for Each Individual Condition Is Often Counterproductive and Sometimes Harmful
When caring for older patients with multiple health problems, following standard clinical guidelines for each individual condition may hurt more than help, according to a new report by the American Geriatrics Society (AGS) that outlines how clinicians can tailor care to better meet these patients’ unique needs. More than half of adults 65 and older have at least three chronic conditions, such as heart disease, diabetes, arthritis, high blood pressure, or Alzheimer’s disease. “Increasingly, healthcare providers are asked to follow standard clinical guidelines—recommendations for care based on research that weighs their safety and effectiveness—but these guidelines often fail to take into account the needs of older adults with multiple health problems,” explains Cynthia M. Boyd, MD, MPH, of the Johns Hopkins University School of Medicine, who chaired the expert panel that developed the new report with colleague Matthew K.
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McNabney, MD, also of the Johns Hopkins School of Medicine. “If a clinician caring for an older adult with these common conditions were to prescribe the medications that standard guidelines recommend for each of these conditions individually, the patient could end up taking too many medications, and running significant risks of drug interactions and potentially harmful side effects,” says Dr. McNabney. Entitled Patient-Centered Care for Older Adults with Multiple Chronic Conditions: A Stepwise Approach from the American Geriatrics Society, the new report was published in today’s early, online edition of the Journal of the American Geriatrics Society (JAGS) and is available at americangeriatrics.org A wealth of related resources, tips, and tools for both clinicians and the public are also available on the AGS website. To help both clinicians and patients make complex treatment decisions, the report outlines five essential
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elements, or guiding principles, of quality care for older adults with ! multiple ! health problems: • Consider patient preferences – The clinician should help patients, and sometimes their family or friends, understand their options for care. Once they understand these options, the patient and healthcare provider should work together to make decisions consistent with the patient’s preferences. • Interpret medical research and evidence – Healthcare providers need to look at the available research to be sure a given treatment approach is suitable for a specific patient, and understand whether there is much uncertainty about whether the approach is likely to work for older adults with multiple health conditions. When deciding which treatments to choose, clinicians and patients should focus on the outcomes that are most important to the individual patient. • Make clinical decisions in the context of risks, benefits, burdens and prognosis – When possible, clinicians should discuss with the patient what is likely to happen both with and without each available treatment. Among other things, healthcare providers should try to determine, and share with the patient, how long it will likely take to benefit from certain treatments. All of this is useful information for PLEASE SAY, “I FOUND YOU IN CASEMANAGEMENT SOCIALWORK.”
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patients who are deciding which treatments are more important to them, and which are less important. • Assess the complexity and feasibility of treatment options – Healthcare providers should keep in mind that older patients are more likely to stop following parts of treatment regimens if they are too complicated, confusing or burdensome. • Optimize treatments and care plans – Clinicians should try to maximize benefits and minimize risks from treatments within an overall treatment plan. Among other things, they should prescribe non-drug treatments whenever appropriate to reduce potentially harmful drug interactions and other side effects.
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ELIMINATE HARM ACROSS THE BOARD Days Since Last Readmission
READMISSIONS PREVENTION:
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Conduct enhanced admission assessment of discharge needs and begin discharge planning at admission
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Conduct formal risk of readmission assessment; align interventions to patient’s needs and risk stratification level
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Perform accurate medication reconciliation at admission, at any change in level of care and at discharge
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Provide patient education that is culturally sensitive, incorporates health literacy concepts and includes information on diagnosis and symptom management, medications and post-discharge care needs
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Identify primary caregiver, if not the patient, and include him/her in education and discharge planning
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Use teach-back to validate patient and caregiver’s understanding
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Collaborate with post-acute care and community-based providers including skilled nursing facilities, rehabilitation facilities, long-term acute care hospitals, home care agencies, palliative care teams, hospice, medical homes, and pharmacists
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Before discharge, schedule follow-up medical appointments and post-discharge tests/labs; for patients without a primary care physician, work with health plans, Medicaid agencies and other safety-net programs to identify and link patient to a PCP
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Conduct post-discharge follow-up calls within 48 hours of discharge; reinforce components of after-hospital care plan using teach-back and identify any unmet needs, such as access to medication, transportation to follow-up appointments, etc.
Send discharge summary and after-hospital care plan to primary care provider within 24 to 48 hours of discharge
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HOSPICE !
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Is persistent overcrowding a problem for your ED?
VITAS breaks the cycle
A recent survey by the American Hospital Association reveals more than 50 percent of surveyed urban and teaching hospitals had EDs that were at or over capacity.1 VITAS care transition support services can help keep your beds turning. • We offer clinical staff trained to discuss goals of care and hospice benefits. • The VITAS admission team is available 24/7. • We can alleviate congestion in EDs by transitioning end-of-life patients to home. • VITAS can provide 24-hour nursing care (continuous care) in the patient’s home, nursing home or assisted living community, when appropriate, to control symptoms • VITAS after hours program provides direct, 24-hour access to clinical experts who have patient information and can dispatch a team member to the bedside any hour of the day or night, even on holidays. A referral to VITAS expands alternatives for transitioning your end-of-life patients.
1.800.93.VITAS • VITAS.com/Illinois 1
American Hospital Association “Taking the Pulse: The State of America’s Hospitals.” Results of AHA Survey of Hospital Leaders, March/April 2010-May 24, 2010.
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Welcome to the Chicago Chapter of Case Management Society of America! We are a non-profit, multidisciplinary group of healthcare professionals working together in case management. CMSA Chicago has been affiliated with the National Chapter of CMSA since 1993. We host seven Monthly (September - May) Educational Meetings and one Annual Conference (April). The location of the events is rotated throughout the communities we serve. Our membership strives to collaborate with the patient, family, healthcare provider and employer to provide the highest possible standard of professional healthcare. Please join us to collaborative efforts through networking and educational efforts. Our mission is to encourage standards of excellence throughout the case management process by providing opportunities for education and networking with other case managers and health care professionals that would improve healthcare outcomes. !
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CMSA Chicago The CMSA Chicago Chapter PO Box 726 Oak Park, IL 603030726 Telephone: (630) 415-2203 E-Mail: info@cmsa-chicago.org
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CASEMANAGEMENTSOCIALWORK.COM!
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The Complete Continuum of Care
Free daily telephone reassurance calls
Compassionate non-medical in-home care
Save up to 65% with Free ABC Rx cards
Escorted tours of assisted living communities
Always Best Care Senior Services ®
Non-medical in-home care • Assisted living services Dedicated to exceeding your expectations ... always
Call one of our Chicago locations today!
Chicago North Chicago West Chicago Southwest
(847) 730-5930 (855) 761-9755 (708) 320-8222
Independently owned and operated offices throughout the United States
!! PLEASE SAY, “I FOUND YOU IN CASEMANAGEMENT SOCIALWORK.” !
16! www.alwaysbestcare.com