Referral Guide
Combining Quality, Compassion and Care
Guide to Senior Care Options & Patient Care Assisted / Alzheimer’s – Home Healthcare – Hospice – Home Care Senior Living - Skilled Nursing & Rehabilitation – Rehabilitation Hospital MOBILE AND DIGITAL
1
CASEMANAGEMENTSOCIALWORK.COM
2
CONTENTS
SYNERGY HomeCare patients receive a high level of quality care in your hospital or facility, which enables them to recover and to return home. As a medical professional, you take pride in this and want to help ensure that high quality care continues as they transition back to daily life at home.
12
Two Great Chapters to Join CMSA Houston/Gulf Coast Chapter & ACMA Greater Houston Chapter Enjoy networking, annual conferences, and education/CEUs FOR MORE INFORMATION: www.cmsahouston.com &
www.acmaweb.org
3
CASEMANAGEMENTSOCIALWORK.COM
Volume 3 Issue 2
Levels of Care
Assisted Living 7 Senior Living community which provides multi-level of senior living options including rehabilitation services, and home healthcare. CONTINUUM OF CARE 8 Senior Living community which provides multi-level of senior living options including rehabilitation services, and home healthcare. HOME CARE 9 Allowing a non-medical home care assistant (caregiver) provide transportation, meals, and daily needs.
HOUSTON/GULFCOAST
SKILLED NURSING & REHAB 20 Licensed and equipped to provide healthcare to meet the needs of more extensive medical issues and to regain mobility, strength, and assist in living after surgery. REHABILITATION HOSPITAL 27 Inpatient rehabilitation hospitals devoted to the rehabilitation of patients with various neurological and orthopedic, and other medical condition to regain strength and stabilization.
HOME HEALTHCARE 15 Allowing patients to remain at home eliminating travel for treatment; alternative to hospital stay or a skilled nursing facility. HOSPICE 19 In-home or facility end of life care for the terminally ill with pain management, comfort and emotional support being the primary mission for the family and regain independence. PRIVATE DUTY NURSING 23 Providing 1-on1 nursing care in the home from register nurses (RNs) or licensed practical nurses (LPN).
facebook/casemgmt
© 2014 CMSW
4
The Leapfrog Group released its 2014 spring Hospital Safety Scores. The report showed an overall 6.3 percent average improvement in hospital ! performance since 2012.
ELIMINATE Advocate Health Care, based in HARM ACROSS THE BOARD Downers Grove, Ill., is one system
five
receiving high marks, especially noting that nine of the health system's hospitals received an A grade.!
Days Since Last KATE KOVICH, ADVOCATE HEALTH CARE'S Readmission VICE PRESIDENT OF PATIENT SAFETY,
Keys to Patient Safety
SHARED FIVE OF THE HEALTH SYSTEM'S KEY STRATEGIES TO CHAMPION PATIENT SAFETY.!
READMISSIONS PREVENTION:
!
Conduct enhanced admission assessment of discharge needs and begin discharge planning at admission
1. Advocate places an emphasis on accountability surrounding health
Conduct formal risk of readmission assessment; align interventions to patient’s needs and risk !outcomes. Ms. Kovich says the health system's overarching goal is to have top stratification level
decile performance in all areas of quality and safety outcomes. "Each year as a Perform accurate medication reconciliation at admission, at any change in level of care and !system, we establish targets for those outcomes, not because of safety scores, but at discharge because believe we owe it culturally to our patients," she says. health literacy concepts and patient education that is sensitive, incorporates ! Provide we includes information on diagnosis and symptom management, medications and post-discharge
careestablishing needs ! Upon the goals, every leader across the Advocate system aligns with Identify primary if not the patient, and include him/her in education and goals and caregiver, guides hospitals to achieving these outcomes, Ms. Kovich says. !these discharge planning "The vision for health outcomes is crystal clear. I think that leader alignment and Use teach-back to validate patient and caregiver’s understanding !accountability are first and foremost the foundation of what we're able to achieve."
!
Send discharge summary and after-hospital care plan to primary care provider within 24 to
48 hours of discharge 2. Developing and implementing a patient safety strategic plan is helping Collaborate with post-acute care and community-based providers skilled nursinghas achieve "breakthrough performance." Whileincluding the health system !Advocate facilities, rehabilitation facilities, long-term acute care hospitals, home care agencies, palliative always kept patient safety in the forefront, Ms. Kovich says, several years back, they care teams, hospice, medical homes, and pharmacists had yet to reach a breakthrough in significantly decreasing adverse events. In 2011, Before discharge, schedule follow-up medical appointments and post-discharge tests/labs; !Advocate began developing a patient safety toMedicaid becomeagencies a high-and for patients without a primary care physician, workstrategic with healthplan plans, other safety-net programs identifyofand link patient tostrategic a PCP reliability organization by to means a thoughtful, manner with the ultimate of eliminating all events of calls serious harm across the health system. Conduct post-discharge follow-up within 48 hours of discharge; reinforce components of !goal after-hospital care plan using teach-back and identify any unmet needs, such as access to
follow-up appointments, etc. "Atmedication, the time, transportation there weren'ttomany organizations we found who had put that strategic thought to patient safety. Since we began our work, we have started seeing in the literature that other organizations are taking a similar approach," Ms. Kovich says.
!
5
CASEMANAGEMENTSOCIALWORK.COM
3. The health system launched a "Safer Surgery Initiative" to reduce potential adverse surgical events. Advocate initiated a three-year effort on safety in operating rooms, which Ms. Kovich notes is the highest area focused of clinical risk in hospitals.. Areas of focus included effective and correct communication during handoffs from the surgeon's office to the OR scheduler, developing an anesthesia protocol, identifying appropriate and necessary lab tests to be completed prior to surgery and implementing a surgical safeguards checklist. Additionally, Advocate launched an OR team training initiative that focused on "minimizing the hierarchy and power distance in the OR so anybody feels comfortable raising a patient safety concern," Ms. Kovich says. 4. Some of the best results are produced from strategically aligned team work. In addition to aligning leaders across the system around health outcomes, Advocate puts teams together to collaborate on specific topic areas. "We have strong teams led by the system to identify best practices and to implement them at all sites across the system," Ms. Kovich says. "There isn't something at hospital A and something different at hospital B." For example, in 2010 Advocate was at the 50th percentile for patient falls when compared to the National Database of Nursing Quality Indicators. Within three years, the system reached the 86th percentile by using an aligned team approach to develop and share best practices. "For Advocate, this reinforces that consistent focus on best practices and a system approach really makes a difference," Ms. Kovich says.
!
5. Leadership plays a crucial role in achieving a high-reliability culture. Every morning at 8:30 a.m., the leaders at each Advocate hospital gather for a daily safety huddle. In the huddle each leader reports any patient safety events, near misses or unsafe conditions that occurred in the past 24 hours and predict any specific risks that may arise in the next 24 hours. The risks could include two patients with the same name on the same unit, critical medication shortages, clinical equipment downtime, a staffing shortage or a projected weather alert. "It creates the shared risk or shared situational awareness of what we as leaders are facing today," Ms. Kovich says. "That 15 minutes lets us establish priorities so we can work together to mitigate those risks." Ms. Kovich adds the daily safety huddles have been "transformational," with leaders verbalizing how the huddles helped them see how their work can directly impact other people. "People have said to me, 'I don't know how we ever did this without the huddle,'" she says. A. Jayanthi ALZ.ORG
6
ASSISTED LIVING
Let us help your families
With private room and companion rooms in each cottage, Unlimited Care Cottages are non-institutional, non-hotel-like setting, perfect for the elder who prefers a peaceful, family environment. Personalized care is able to be tailored to the individual’s personal daily needs. Call 713-419-2609 or send us an email to let us introduce you to our care setting! We are the best in assisted living cottages, serving residents of Spring, The Woodlands, Conroe, and Kingwood, Texas!
CHECK US OUT!! unlimitedcarecottages.com
facebook.com/unlimitedcarecottages
Providing Cottage Care for over 15 Years!
7
CASEMANAGEMENTSOCIALWORK.COM
Continuum of Care
0"
Treemont Retirement Community
A comprehensive Senior Community that includes Independent Living, Assisted Living, Skilled Nursing Services is nestled on 9 wooded acres off Westheimer Road. Treemont Retirement Community has provided seniors with a quality lifestyle for 40 years in the Memorial and West Houston area. The Facility’s reputation is synonymous with excellence.
Treemont Retirement Community Amenities Include:
Independent Living Services: Private Luxury Apartments Beautifully Landscaped Courtyards
Walking Paths Three Delicious Meals Per Day Housekeeping Room Service for Meals is Available Controlled Access Laundry Rooms Available on Premises Personal Laundry Service Available Library Gift Shop Recreation/Exercise Room Scheduled Transportation Assigned Covered and Uncovered Parking All Utilities Paid Except Phone and Cable Beauty Shop Private Rooms May Be Reserved For Special Occasions and Celebrations
Treemont Health Care Center: Assisted Living Services: ALF #0409
24 Hour Caregiver Assistance Social and Recreational Events Assistance with Bathing and Dressing Monitoring of Resident Medications 3 Delicious Meals Per Day
Skilled Nursing Services:
Medicare Certified 24 Hour Nursing Services Post Hospital Rehabilitation Care
Personal Care by Senior Allegiance:
Providing Certified & Licensed Home Health and Personal Care throughout the community.
""
"
Call For A Tour Today! 713-783-4100 2501 Westerland Drive, Houston, Texas 77063 8 taylorm@treemonthc.com
HOME CARE
9
CASEMANAGEMENTSOCIALWORK.COM
HOME CARE
NEED HELP? HERE’S WHAT WE DO…
WE WILL:
Sit with you in the hospital 24/7 Provide transpor tation home Stay with you in your home 24/7 Help you with personal care Take you to your appointments Help you with medications Prepare your food Keep your surroundings clean and safe
DON’T FEEL GUILTY IF YOU CAN’T DO IT ALL! Professional Caretakers 50 Briar Hollow Lane, Suite 260 Houston, TX 77027
(877 ) 921- 9500
WWW.PROFESSIONALCARETAKERS.COM Serving Texas since 1988 Licensed – Bonded Non-Medicare
10
HOME CARE
11 CASEMANAGEMENTSOCIALWORK.COM
QUALITY CARE CONTINUES AS
PATIENTS TRANSITION BACK TO DAILY LIFE AT HOME
Your patients receive a high level of quality care in your hospital or facility, which enables them to recover and to return home. As a medical professional, you take pride in this and want to help ensure that high quality care continues as they transition back to daily life at home.
Whether a patient has experienced a heart attack, stroke, surgery, orthopedic injury or other illness, for your patients and their families, there are many new and unexpected challenges as they return home. It can be confusing to understand and coordinate discharge instructions, decipher prescriptions and manage new medications. It may be difficult to schedule and get to follow up appointments with doctors. There may be new mobility issues requiring the use of durable medical equipment like a walker, bedside commode or shower stool. The patient may not have the ability to prepare meals or may need encouragement to eat a nutritious meal. They may find it difficult to keep up with housework and as a result, do too much when they should be resting.
They may try to do things they aren’t ready for, like showering without assistance, which may put them at risk for a fall and another injury. They may even experience depression or anxiety that saps the emotional strength that is so important to a successful recovery. If a patient is also struggling with issues related to dementia or Alzheimer’s, these challenges may be amplified and can be overwhelming. When you consider all of the challenges your patient may face, it’s no surprise that one in five Medicare patients ends up back in the hospital within one month of discharge. There are many factors that affect readmissions, including patients’ 12
diagnoses and severity of illness, patients’ behavior, such as adherence to discharge instructions and the availability and quality of post-discharge care.* You’ve taken great care to provide detailed and helpful discharge instructions, but what happens after the patient is discharged? Is there a qualified and able family member in place to help see that your instructions are consistently implemented? Unfortunately, this is often not the case. The good news is that SYNERGY HomeCare is an effective partner in helping ensure adherence to discharge instructions and enabling a safer and healthier environment in which to recover. We do this with our proprietary C.A.R.E. team approach. C.A.R.E. stands for Coordinated and Responsive Engagement. This means that we don’t just provide home care, we provide solutions. THESE SOLUTIONS HAVE PROVEN TO BE INSTRUMENTAL IN HELPING OUR REFERRING HOSPITALS AND FACILITIES REDUCE READMISSIONS AND ACHIEVE BETTER PATIENT OUTCOMES.
SOME EXAMPLES INCLUDE:
• Assistance with discharge coordination • Assistance with transportation and settling at home • Help ensure discharge instructions are followed • Scheduling of medical appointments • Transportation to/from medical appointments and note-taking • Prescription pick-ups • Medication reminders • Transfer assistance • Assistance with bathing, dressing and personal care • Fall and injury prevention • Meal preparation • Change in condition alerts • Housekeeping/laundry • Errands and shopping • Companionship to help relieve the anxiety and depression that is
common following heart attacks, strokes or other serious illness or injury
13 CASEMANAGEMENTSOCIALWORK.COM
Combining Quality, Compassion and Care SYNERGY HomeCare C.A.R.E Teams are led by experienced, knowledgeable care managers that work directly with patients and their skilled health care providers to build a transitional care plan for each unique patient. This care plan is designed for one purpose only…to achieve a successful patient outcome! SYNERGY HomeCare caregivers are available from 2 hours to 24 hours per day, 7 days per week. All are fully trained, insured and background checked for safety and peace of mind. Our training even includes memory care strategies to assist in calming anxiety and addressing safety concerns that are common for individuals coping with dementia or Alzheimer’s disease. To learn more, please contact us at 832-266-1704. Please see our Ad on page. 9
*Health Policy Brief – HealthAffairs/Robert Wood Johnson Foundation, November 2013
14
At BrightStar Care®, our goal is to improve the quality of life of those entrusted to our care. We are here to make more possible everyday and help you get the most out of life. > Companion and personal care services > One hour to 24-hour care > Bathing, dressing, personal care > Medication management > Post-op, rehabilitation, hospital sitter care > Meal prep, errands, transportation > All care and staff overseen by a Registered Nurse
ServingAustin, Houston and Surrounding Areas Serving Round Rock, Georgetown & Surrounding Areas BrightStar of North Houston BrightStar of The Woodlands 281-367-7827
Friendswood 512 452 9800 281-606-4335
7703 N. Lamar Blvd., Austin, TX 78752 BrightStar of Sugar LandSuite 418, BrightStar of Bellaire 2508 Williams Dr, Ste 255 Georgetown, TX 78628 W. Houston/Katy SW Houston 281-201-3700 Locally Owned and Operated by Chad 832-730-1255 & Rhone McCall
15 CASEMANAGEMENTSOCIALWORK.COM See our listings on pages 60 and 72.
61
HOME HEALTHCARE
Prevent hospital readmissions ResCare HomeCare is your solution Skilled Nursing Complex Medical Care Physical, Occupational & Speech Therapies Discharge your patients smoothly. Get them on a path to a speedy recovery while at home — where we all want to be.
281.428.2244 ResCareHomeCare.com
16
 Â
HOSPICE Â
Â
Caring for Moments That Matter AseraCareÂŽ provides compassionate end-of-life care when it’s needed most. With more than a decade in service, our caring team of professionals provides hospice services that meet the physical, social and spiritual needs of each patient. Our services include: UĂŠĂŠ->“iĂŠ`>ÞÊ>`Â“ÂˆĂƒĂƒÂˆÂœÂ˜Ăƒ UĂŠĂŠ ĂŒÂ‡Â…ÂœÂ“iĂŠĂ›iÂ˜ĂŒĂŠV>Ă€i UĂŠĂŠ-ÂŤiVˆ>Â?ĂŠĂƒiĂ€Ă›ÂˆViĂƒĂŠvÂœĂ€ĂŠĂ›iĂŒiĂ€>Â˜Ăƒ UĂŠĂŠ iĂ€i>Ă›i“iÂ˜ĂŒĂŠĂƒiĂ€Ă›ÂˆViĂƒ If you or your loved one would benefit from holistic support provided by a caring team of professionals, contact us today.
AseraCare - Houston 1235 North Loop West, Suite 215 Houston, TX 77008 713-864-2626 www.AseraCare.com This agency welcomes all persons in need of its services and does not discriminate on the basis of age, disability, race, color, national origin, ancestry, religion, gender, sexual orientation, source of payment, or ĂŒÂ…iÂˆĂ€ĂŠ>LˆÂ?ÂˆĂŒĂžĂŠĂŒÂœĂŠÂŤ>Þ°Ê -‡££äxLJ£ÎÊ £äx
 Â
17 Â Â CASEMANAGEMENTSOCIALWORK.COM Â
HOSPICE
Beaumont
409-832-6700
18
Houston
Houston North
281-277-1151 210-520-7734
HOSPICE
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/Texas 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.
19 CASEMANAGEMENTSOCIALWORK.COM
SKILLED NURSING & REHAB !
!
baywood crossing rehabilitation & healthcare center
The$Next$Step$to$Recovery$
Our Transitional Care Unit specializes in providing the newest technologies for those requiring rehabilitation. Offering physical, occupational, and speech therapy, our rehabilitation team has the expertise needed to design a specific therapy program based on each patient’s needs. Our spacious gym allows each patient to utilize every aspect of our therapy program to their fullest capability. We specialize in a range of diagnoses to include orthopedic and stroke recovery as well as offering services to medically complex patients. This can include IV therapy, wound care, and much more. 5020 Space Center Blvd Pasadena, Texas 77505 (713) 575-1800 www.baywoodcrossingrhc.com OUR FRIENDLY AND PROFESSIONAL IN-TAKE ! COORDINATORS ARE READY TO ASSIST YOUR PATIENTS, AND THEIR LOVED ONES. CALL TODAY
20
SKILLED NURSING & REHAB
21 CASEMANAGEMENTSOCIALWORK.COM
22
SKILLED NURSING & REHAB
A name you can trust for rehabilitation and health care.
Post-Surgical, Short-Term Rehab Heartland - Austin Heartland - Bedford ManorCare - Dallas Heartland - Fort Worth Heartland - North Richland Hills Heartland - San Antonio Heartland - San Antonio North ManorCare - Sharpview ManorCare - Webster ManorCare - West Houston ManorCare - Willowbrook
800.736.4427 www.hcr-manorcare.com
23 CASEMANAGEMENTSOCIALWORK.COM
PRIVATE DUTY NURSING
24
Closing the Gap Between
Case Managers & Coders There’s a communications gap between case managers and coders that generally reveals itself too late in the patienttransition process: after the patient’s been discharged and when an auditor is eyeing discrepancies to flag. Fixing that is like shutting the barn door after the horse is gone. Case managers, though, are well-positioned to eliminate that communications gap. After all, case managers have the information about the patient’s discharge status and all other facets of that discharge that can affect reimbursement: where the patient ultimately went, to what level of care and when the services started. Coders forced to rely on what the physician initially ordered for post-acute care may not have specifics about the actual discharge. Case managers who facilitate the transition of care, however, do have that information and must ensure that coders get it too. Otherwise the wrong discharge codes entered in a patient’s claim for payment can result in financial or legal penalties. Yes, assigning a discharge code is the responsibility of coding professionals. Yet it’s case managers who know the details and appreciate the importance of clear documentation on the revenue cycle and other issues of post-acute care. But it’s not enough to know the facts: Case managers need to communicate to coders what they know and when, and that’s at the time of discharge. For example, it makes a difference in coding when a patient is transferred to a skilled nursing facility (SNF) for extended care for rehabilitation, or to custodial care or hospice. It also makes a difference if the medical record shows a referral was made to a SNF (Code 03) and the patient subsequently was discharged to a family member with no referral (Code 01).
25 CASEMANAGEMENTSOCIALWORK.COM
Discharge status codes are used for assignment of MS-DRGs, monitoring the post-acute transfer policy, tracking referral “It’s Not a Turf War. types, readmission analysis and tracking It’s a Fight for What’s network usage and leakage, among other things. To assign the correct MS-DRG for a Right…..” Medicare patient, the age, sex, discharge status, principal diagnosis, secondary diagnosis and procedures performed are reported. Notice that discharge status has equal weight with diagnosis and procedures; not everyone appreciates that. One way to improve the accuracy of coding is to increase awareness about its importance and to discuss it with coders and case managers. Ideally, that discussion is coupled with an electronic records system that captures in a structured workflow the most up-to-date information, from start of care to level of care, that has an immediate and significant impact on getting claims processed without incident. Jackie Berman
26
REHABILITATION HOSPITAL
27 CASEMANAGEMENTSOCIALWORK.COM
28