Collaborative Case Management | COVID-19 Special Issue by ACMA

COLLABORATIVE CASE MANAGEMENT

A Peer-Reviewed Journal for Case Management and Transitions of Care Professionals COV I D - 19

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SPECIAL ISSUE:

COVID-19 The Impact on Case Management and Transitions of Care T H E O F F I C I A L P U B L I C AT I O N O F T H E A M E R I C A N C A S E M A N A G E M E N T A S S O C I AT I O N

COVID-19 | SPECIAL ISSUE

COLLABORATIVE CASE MANAGEMENT

Healthcare Leaders Share Valuable Learnings from COVID-19 to Improve Care Transitions

Revolutionizing Utilization Review for Resource-Challenged Times

Documenting COVID-19 Patients – Specificity is Key

Discharging in the Age of COVID-19

Caregivers Share Their COVID-19 Experiences, Struggles and Advice

A New Normal or Simply a Detour? COVID-19 and Case Management

Flying Above the Medical Transport Challenges of a Global Pandemic

Got Medicare? Get a No-Cost Test for COVID-19

Speeding Up Discharge Communication with Post-Acute Providers in a Crisis

Adapting and Growing in the Face of a Pandemic

Home Care Rapidly Adapts to Impacts of COVID-19

Utilization Management is Broken. Now is the Time to Rebuild.

Phil Eaton: Road to Recovery

How ADT Health Helps Seniors Stay Safe and Healthy This Summer “Case management in hospital and health care systems is a collaborative practice model including patients, nurses, social workers, physicians, other practitioners, caregivers and the community. The case management process encompasses communication and facilitates care along a continuum through effective resource coordination. The goals of case management include the achievement of optimal health, access to care, and appropriate utilization of resources, balanced with the patient’s right to self-determination.” Approved by ACMA membership, November 2002

Thank you for reading this special issue of Collaborative Case Management which includes contributions from ACMA industry partners related to the fight against COVID-19. By supporting our industry partners, you support ACMA’s continual goal of providing relevant educational content for case management and transitions of care professionals across the country.

PUBLISHER L. Greg Cunningham, MHA CEO ACMA • Little Rock, AR lgcunningham@acmaweb.org EDITOR Jon Vickers ACMA • Little Rock, AR jvickers@acmaweb.org Article Submission Guidelines: Article proposals may be submitted to jvickers@acmaweb.org in one of the following formats: completed article/ manuscript, article abstract or article proposal. Submissions should include three learning objectives for your proposed article; outcomes information as applicable to the model/program/ intervention described in the article; author(s) bio information: name, contact information, organization, position, education/credentials; and statistical data and outcomes (including p-values) whenever applicable. Collaborative Case Management is a peer-reviewed journal published quarterly by the American Case Management Association (ACMA). Subscription is a benefit of membership in ACMA. Memberships are available at $135 per year. Student membership is open to individuals enrolled in a full-time academic program at $60 per year. More detail about membership categories is available at the ACMA website, www. acmaweb.org or by calling 501-907-2262. Photocopying: No part of this publication may be reproduced in any form or incorporated into any information retrieval system without the written permission of the copyright owner. For reprint permission, please contact: American Case Management Association (ACMA) 11701 West 36th Street Little Rock, AR 72211 Telephone: 501-907-ACMA (2262). The statements and opinions contained in the articles of Collaborative Case Management are solely those of the individual authors and contributors and not of the American Case Management Association. The Publisher and Editor disclaim responsibility for any injury to persons or property resulting from any ideas or products referred to in the articles or advertisements. Copyright © 2020 American Case Management Association All rights reserved

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Healthcare Leaders Share Valuable Learnings from COVID-19 to Improve Care Transitions By B.J. Boyle, Vice President and GM, Post-Acute Insights at PointClickCare Senior living, long-term, and post-acute care facilities, among the hardest hit by the COVID-19 crisis, are reexamining care transitions to better protect their patients, manage risk, and prepare for challenges that may lie ahead. To help, leading providers and payors in healthcare share their most valuable takeaways and the lessons they’ve learned during the COVID-19 pandemic. Together, we can leverage experiences and newfound knowledge to navigate this challenging time and help to create our new normal. Here leaders share four valuable lessons impacting care transitions and patient experience:

Understand your patient population to build an effective preparedness plan. Skelly Wingard, Mid-Atlantic Vice President, Continuum of Care at Kaiser Permanente, advises organizations to create or improve their preparedness plan by addressing staffing, support and supplies, and cautions that effectiveness depends on a thorough knowledge of patient populations.

When they are not physically seeing their doctor or case manager, what is the customer experience? “We need chart level data to identify highrisk patients and the resources they need, and an understanding of our partners so we know who has resources—and a sophisticated model—to help,” says Wingard. “The more you understand that, the more equipped you are to react and intervene when tragedy strikes.” She advises organizations to include all constituents—key administrators, associations, departments of public health, local and county health services, health plans, med groups, and others.

“Your plan needs to dictate how these entities work together and align to be effective and efficient,” she says.

proactively triage patients, coordinate care, and manage transitions.

Knock down silos. Collaboration is key to patient experience.

“More transitions mean higher risk, including risks to paramedics, nurses and other care providers patients interact with during transit,” says Wingard. “Data helped us use transitions sparingly and only when appropriate.”

Collaboration and communication between hospital systems and post-acute care systems is critical to managing a crisis, addressing hot spots and providing a better patient experience.

Patient experience has, perhaps, never been more important.

“COVID made us think about the importance of the patient experience and ensuring team members at the skilled nursing facilities have as much time as possible to spend with patients to care for them,” said Lori Baker, Director, Preferred Provider Post Acute Network at TriHealth. “Both hospitals and skilled nursing facilities can get overwhelmed with volume, rapidly and repeatedly cycling patients from hospital to nursing facilities. It’s important to minimize the amount of time spent on manually entering patient data to enable team members to spend time with patients. Preparation and electronic data exchange allow us to better collaborate without post-acute providers and ensure a more seamless transition.”

A marked increase in televisits and a change in patients’ expectations of when and how often they need to seek care means providers may be seeing less of their patients. Koenig estimates a 30-40 percent drop in unnecessary visits during the crisis—likely tied to fear of catching COVID-19, the elimination of elective procedures during quarantine periods, and limited availability—and predicts the trend will continue.

Successful care transitions depend on data.

It’s likely that patient experience will become an important component of infectious disease planning playbooks. “Some of our dashboards and patient tracking methodologies will be scalable for anything,” says Baker. “We now know how to track our data.”

Many organizations have developed dashboards to gather, analyze, and share COVID-19 data, leveraging it to make more informed decisions.

“When they are not physically seeing their doctor or case manager, what is the customer experience?” says Wingard. “We’ve become successful in case managing patients in a remote way, but we need to be mindful of what that feels like for a patient over a longer term.”

Dr. Tere Koenig, an internist geriatrician and Executive Vice President and Chief Medical Officer for Medical Mutual, says her team quickly created a COVID dashboard looking at who had been admitted with COVID or potential COVID and who needed high level care, such as ICU, so they could understand capacity needs and adjust resources, as well as provide staterequired weekly updates on SNF cases.

LOOKING AHEAD

Similar dashboards also helped teams at Kaiser and TriHealth, who assessed patient populations and testing status to

B.J. Boyle is the Vice President and GM of Post-Acute Insights at PointClickCare. He can be reached at BJ.Boyle@pointclickcare.com.

Though still in the beginning stages of managing this pandemic, we can better prepare for and respond to challenges as they arise by learning from the lessons we’re sharing along the way. To read the full interview, visit www. pointclickcare.com/ACMA. ABOUT THE AUTHOR

Revolutionizing utilization review with artificial intelligence Health systems and hospitals require effective solutions and technologies to combat the modern challenges impacting traditional utilization review (UR) processes. Strategies that bring together talent with artificial intelligence (AI) can revolutionize UR, improve efficiency and accuracy, and enable case management staff to redirect efforts toward other objectives. The Optum Case Advisor AI-powered technology platform and related optional services can: ®

™

• Drive efficiency to do more with less • Improve accuracy to help obtain all deserved reimbursement • Provide flexibility to meet your individual needs FOR MORE INFORMATION, VIEW OUR BRIEF CASE ADVISOR VIDEO AT OPTUM360.COM/TRANSFORMINGUR

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Revolutionizing Utilization Review for Resource-Challenged Times By Kurt Hopfensperger, MD, JD While patient care remains hospitals’ primary concern, the financial effects of the COVID-19 crisis will linger for many months, perhaps years. Many hospitals face significant revenue decline due to decreased census and resource constraints related to furloughed or laid-off staff. This crisis also exposed the severity of pre-existing challenges. Medical necessity now accounts for 29% of all denials and 53% of all denial write-offs.1 At the same time, commercial payer appeal success has dropped to 50%.1 The next few months will be difficult both clinically and administratively. Hospitals need new processes and technologies to emerge from this emergency in a financial condition that allows them to serve their populations. The old utilization review (UR) models no longer suffice. THE PROBLEMS WITH TRADITIONAL UR Traditional UR models predate value-based care, the Two-Midnight Rule and — in some cases — the development of the physician advisor role. COVID-19 has strained hospital operations and highlighted the weaknesses of these UR models: • Lack of appropriate expertise at the right time: Medical necessity decisions are often made without an appropriate level of expertise and evidence-based medical research, and often not at the right time.

Artificial intelligence (AI) can revolutionize UR, improving efficiency and accuracy, and enabling case management/UR teams to refocus their staff to more strategic objectives.

Hospitals need to consider new ways of using their talent, new technologies and new processes to share insights to ensure that their UR is generating value and supporting organizational objectives. Apply these five strategies to update your UR process to meet modern revenue cycle needs: 1) REDUCE MANUAL INITIAL CASE STRATIFICATION WITH AI

• Time sink: UR is a slow process, and every minute spent on medical necessity detracts from time case managers can devote to other strategic objectives, such as length of stay and avoidable day management.

Most UR processes involve a first-level review in which case managers apply a standardized criteria set (usually InterQual or Milliman) to assign an initial inpatient or outpatient status. This initial case stratification is time-consuming, taking up to 15 minutes per case.3 It requires case managers to input the attributes of each case, one at a time. Each of these manual steps introduces the possibility of error. Moreover, even if the case manager enters every piece of data correctly, this firstlevel review still only accounts for broad, general standards — not the particular nuances and gradations of a particular patient case.

The same old thinking about utilization review cannot address these problems. Hospitals need to consider new ways of using their talent, new technologies and new processes to share insights to ensure that their UR is generating value and supporting organizational objectives.

However, initial sorting of cases can be vastly improved with advanced technology. AI excels at repetitive processes, such as loading case details, and can quickly check all cases against a customizable sorting threshold. Leveraging AI for initial case stratification allows hospitals

• Error-prone medical necessity case reviews: Medical necessity requires the review of a large amount of case data. This process is tedious and prone to errors.

to review each case according to the same high, consistent standard quickly and efficiently. A more standardized process yields more consistent results. 2) ELIMINATE CASE REFERRAL RISK While the decision to send a case for physician advisor review should be based on clinical risk factors, this isn’t always the outcome. On the front end of the UR process, case managers review hundreds of cases for the same payers, and they learn payer habits as a result. This knowledge can improve the UR process, but it can also condition case managers to incorrectly anticipate payer denial decisions. If they believe a payer won’t approve a case as inpatient when it fails first-level inpatient criteria, case managers may simply leave it as outpatient, denying the case a chance for further review. This is often referred to as a “silent denial.” Sometimes, “gray cases” that aren’t clearly inpatient or outpatient arise when a physician advisor isn’t available, and case managers accept the results of first-level criteria instead of waiting for a physician advisor review. Though they are simply trying to operate efficiently amid heavy workloads, case managers may inadvertently miss the opportunity for appropriate inpatient reimbursement. Machine learning, a type of AI technology, can quickly review patient records and sort cases for physician advisor review based on the medical facts, removing subjective opinion from the decision to refer a case to a physician advisor. By eliminating this case referral risk, hospitals can ensure that cases that need it can benefit from an additional review based on AI learning from a large database of past medical necessity reviews and recommendations. 3) REFOCUS STAFF TO HIGHER VALUE TASKS Changing payment models require case management teams who also often have UR responsibility, to focus on tracking and ensuring the accuracy of the quality measures upon which value-based reimbursement — accounting for

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34% of health care payments in 20174 — depends. These concerns affect not only a single case but can influence overall reimbursement from a given payer. In addition to requiring a different set of expertise, these vital priorities require time and attention that case management teams often do not have due to heavy workloads and staff shortages. Nor does the addition of these new responsibilities replace case management’s medical necessity responsibilities. By streamlining initial case stratification, AI can save case managers time, which they can reallocate to improving the quality metrics that affect value-based contract performance and reimbursement. Refocusing staff to prioritize these quality measures is no longer optional, it’s essential. AI can help unlock the bandwidth needed for this shift in responsibility. 4) USE PHYSICIAN ADVISORS MORE EFFECTIVELY Not only can AI help ensure cases are referred to physician advisors only when necessary, but it can also help make their case reviews faster and more accurate. Typically, reviewing a case requires physician advisors to search the patient record — which can be several dozen pages — for the most relevant and crucial factors indicating patient acuity. Once they’ve scoured the patient record, they must judge whether the acuity is more appropriate for inpatient or outpatient status. This takes careful deliberation. Without AI support, some physician advisor reviews can take between 30 and 60 minutes.5 And, of course, the physician advisor must document this decision, along with any supporting clinical research and industry standards that would defend it from denial and form the basis of any potential appeal argument. Most physician advisors lack a library of clinical research to support these determinations. Even if they do have such a library, it ages quickly if not continuously updated with the latest medical research and regulatory changes. And, of course, searching through that library takes even more time, slowing down the process. AI technology can vastly accelerate the physician advisor review process by quickly highlighting the most important clinical factors affecting medical necessity from the medical record to aide physician advisors. Using AI in this way can increase physician advisor review efficiency by up to 30%.6 And by reducing the time spent on each individual review, hospitals can prevent cases requiring a review from slipping through the cracks. 8

At the same time, clinically intelligent AI can call up the most relevant and supportive material based on a case’s clinical risk factors, avoiding a lengthy search through journal articles and supportive medical research material for which no single physician advisor has time. Physician advisors need this medical research to more effectively defend against concurrent and retrospective denials. These two functions can save significant review time and improve accuracy, which can reduce denials and improve revenue integrity. Physician advisors can handle more cases in the same amount of time or devote that time savings to other responsibilities. 5) ACCESS KEY INFORMATION QUICKER AND EARLIER IN PROCESS When properly applied and clinically intelligent, AI can ensure that hospitals apply expertise, knowledge and experience at the right steps along the UR process. For example, the same AI model that improves initial case stratification can jump-start physician advisor reviews. This provides clinicians and case management/UR staff with a strong foundation upon which they can make the best use of their own clinical judgement and knowledge. Transmitting this information from one stage of utilization review to another can produce significant time savings. Likewise, much of the research and evidencebased justification produced by a physician advisor review can provide a strong foundation for a potential appeal, ensuring that appeal teams can address denials faster and more effectively. By assigning status correctly up front, UR teams save time by preventing additional rounds of review.

STRIVE OR THRIVE? In the current climate, every reimbursement dollar counts more than ever. Amid revenue shortfalls, each hospital team and department is asked to do more with fewer resources. Case management teams work hard, but they need to work even more efficiently and effectively. Evolving UR through improved processes, refocused resources and powerful artificial intelligence allows hospitals to operate more efficiently and successfully deliver value. ABOUT THE AUTHOR Kurt Hopfensperger, MD, JD, is regional vice president for provider relations and education for Optum Physician Advisor Solutions. He is a diplomate of the National Board of Medical Examiners and a member of the Health Law Section of the American Bar Association. FOOTNOTES 1. Advisory Board. 2019 Hospital Revenue Cycle Benchmarking Survey. 2. Advisory Board. 2019 Hospital Revenue Cycle Benchmarking Survey. 3. Optum360 internal study, 2019. 4. Health Care Payment Learning & Action Network. Measuring Progress: Adoption of Alternative Payment Models in Commercial, Medicaid, Medicare Advantage, and Medicare Fee-for-Service Programs. October 22, 2018. 5. Internal Optum Physician Advisor Solutions data, 2019. 6. Optum360 internal study, 2019.

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Documenting COVID-19 Patients – Specificity is Key By Dr. Daniel L. Wagstaff, MD, FACP, FHM, CCDS The COVID-19 virus has caused enormous worldwide disruption over the past several months. Just as this tiny virus has caused huge impacts, small changes in documentation have caused significant losses of vitally important revenue to our healthcare systems. Recently we have begun to see an increase in denials for COVID-19 diagnoses. With uncertainty regarding fiscal year reimbursements, elective surgeries volumes, and staffing, it is more important than ever for hospitals to get reimbursed at the appropriate level for the care of very sick patients, including patients with COVID-19. Of course, first and foremost, we want to provide the interventions and treatment needed to restore our patients’ health and protect our communities. But, we also need to take care of the financial health of our hospitals. Complete, specific, and proper documentation will not only help the healthcare system’s revenue cycle, but it will also prevent retrospective audits and improve quality metrics for individual clinicians. How do we address this challenge? We must provide a higher level of specificity and clarity for cases where multiple conditions are contributing to making a patient very sick. The health of our hospitals depends upon us making this effort. DOCUMENTATION TIPS FOR COVID-19 Coding for Risk Adjustment: • Diagnose/document using coding-based language as much as possible • Make sure the diagnosis(s) is in the chart at least once • Document to the greatest level of specificity • Secondary Diagnoses: bucket into one of 3 groups – Not sick, sick, and very sick

NO SOI

CDI TIPS FOR COVID-19 Be specific with the following: • Pneumonia - type, viral, bacterial (Gram Neg, MRSA, etc.), aspiration? • Respiratory Failure - Acute, Chronic, Acute on Chronic? • Sepsis - Septic shock, underlying infection, organism? • Renal Failure - AKI, ATN, CKD, and stage? • Type 2 MI – Demand Ischemia, underlying cause? THE NEW COVID-19 ICD-10-CM CODE • Applies to all patient types • The intent is to code for only confirmed cases of COVID-19 • Provider’s diagnostic statement or a positive COVID-19 test result, assign code U07.1 • The link between a positive test result and an acute respiratory condition is not required • If COVID-19 test results are positive after discharge, Code U07.1 may be used • Assigning U07.1 as the principal diagnosis depends on the circumstances of admission

COMORBIDITY/ COMPLICATION

MAJOR COMORBIDITY/ COMPLICATION

NOT SICK

SICK

VERY SICK

Altered Mental Status

Encephalopathy

Metabolic Encephalopathy

DOE, Orthopnea

Chronic Respiratory Failure

ARDS

Hypotension

Shock

Septic Shock

(CC,

5SEVERITY)

(MCC,

555SEVERITY)

It’s essential to keep in mind that the principal or secondary diagnosis of COVID-19 is based on the physician’s clinical judgment of how sick the patient is, notwithstanding a positive or negative test. Please remember that specificity is critical, not only for COVID-19 but for all documentation in the chart so that appropriate diagnoses, DRGs, and quality metrics to be assigned. Changing a few words can have an enormous impact on accurately portraying the severity of illness and the associated medical necessity issues. Amid all of the confusion and uncertainty this pandemic has caused, this steadfast principle remains clear: the only defense against inappropriate COVID-19 denials is complete, specific, and appropriate documentation. Providers who paint a picture with their words significantly reduce the risk of being denied full reimbursement for treating these incredibly sick patients. ABOUT THE AUTHOR Dr. Daniel L. Wagstaff, MD, FACP, FHM, CCDS has two decades of experience and is a practicing physician advisor with Sound Advisory Services. Dr. Wagstaff presented this information in the latest Sound Advisory Services webinar, COVID-19 Admissions: Getting Status Right and Preventing Denials. To view the webinar: https:// bit.ly/379hD8T 11

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Discharging in the Age of COVID-19 By Paula Sotir, BSN, MGA, Certified Senior Advisor The saying “It takes a village to raise a child” originates from a popular African proverb on how a community comes together in that culture to ensure a child’s health, well-being, and safety. I was thinking about that phrase as it relates to seniors in the era of COVID-19, and even during normal times. With all the demands placed on case managers to meet discharge goals, how do you safely discharge a patient back home or into a safe senior living community? The world of placing clients — especially senior clients — has certainly changed during the COVID-19 pandemic, but a case manager’s need to find safer senior living options not only lives on, it has been thrown into fast-forward mode. A CASE FROM THE FRONT LINE June, an amputee, was admitted to a rehab facility for sepsis, diabetes, a stage 4 ulcer and severe vascular issues in her remaining leg. She was bedridden and needed a Hoyer-Lift for transferring. Her treatment goals included keeping her functioning leg and not spending her remaining days in a nursing home, especially since her husband and family couldn’t visit. With the discharge approaching, the case manager was determined to provide the safe alternative her patient was seeking with hospice services. Challenges like these sometimes force healthcare professionals to reevaluate their available community resources and form strategic alliances to help their patients meet their discharge goals. This case was no different. HELP FROM OUTSIDE Giving June’s family a list of local senior living communities to find a suitable place was not a safe option for them due to the specialized care needed. The biggest concerns were finding a community that could care for a resident with post-discharge needs including diabetes and requiring a Hoyer-Lift. The case manager wanted a successful and timely discharge. She called on the specialized skills of a local placement advisor to meet with

June and her family to help them navigate living options within the COVID environment. Paula, a CarePatrol advisor with a BSN, recognized the difficulty of this case, but like June’s case manager, wanted to grant her last wish — the dignity of not dying in a nursing home.

If it takes a village to raise a child, it also takes a village to ensure that your discharge clients have a community of support. There were two communities in the area that met June’s care needs and financial means. In a non-COVID world, June’s family would have been able to personally tour the community with Paula to evaluate her potential compatibility; however, during the pandemic, Paula was able to arrange for a virtual tour as the next best thing. June’s family was elated to find one they felt she would love. Paula and the case manager divided up all the tasks needed to complete the discharge from the rehab and admission into the living community. Details were followed meticulously, including having personal protective equipment (PPE) for June when she was transferred to her new home. TIMELY SOLUTIONS With all the demands on case managers and social workers to meet the goals of a safe and timely discharge, COVID has certainly changed

the way we think of the concept of working with community resources. We have learned many things during this pandemic that weren’t taught in school, rather, they were easily learned from the heart. Even more now, it takes teamwork to grant wishes. Case managers do not have the time to study and keep track of which facilities are still accepting clients, let alone an individual facility’s protocols for accepting new residents such as who needs a negative COVID-19 or even a double negative COVID-19 test, or which assisted living quarantines their new residents and which do not. Families have not been able to visit their loved ones, so communication to families has become harder -- and a little clunkier. In a time that has forced us to all completely retool the way we do business and find strategic solutions faster than ever, we are relying on each other more and more to “get through this together.” If it takes a village to raise a child, it also takes a village to ensure that your discharge clients have a community of support. CarePatrol is here to partner with you on timely, custom solutions. A SOCIAL WORKER FOUNDED COMPANY The CarePatrol franchise was founded in 1993 by social worker Chuck Bongiovanni after he observed the trauma of a family whose loved one was placed in the wrong type of facility. It became the pioneer organization of the nowthriving senior placement industry. Today, we still hold our core values, and we’ve helped thousands of families make safe choices all over America. We have pre-screened over 36,000 care providers nationwide so we know their strengths, their care history, and the patients they can best serve. CarePatrol is a completely free service to your patients because we are compensated by the communities in our network. Learn more about how we can partner on safer senior living options here.

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Caregivers Share Their COVID-19 Experiences, Struggles and Advice Craig Hospital | May 29, 2020 Since the COVID-19 outbreak began, people around the world have experienced jarring changes. It seems that no community has been left untouched by the impact of social distancing and stay-at-home orders. Caregivers of people with brain injuries already face a distinctive set of challenges in their day-to-day lives, and a pandemic has added a difficult new facet to their routines, activities and wellbeing. Meagan Beard, LCSW, an outpatient clinical care manager at Craig Hospital, a specialty rehabilitation hospital for people with brain and/or spinal cord injuries, has gotten calls from many of her patients’ caregivers looking for support during this unprecedented and challenging time. “We tell our patients to go out and live life when they leave our hospital, to use community resources, get to know people, create social networks. But they can’t do that right now,” Meagan says. “It’s hard to provide enough encouragement when resources aren’t there at the moment. I can only imagine how families are trying to manage their loved ones and their families with all of the uncertainty. These caregivers do so much for their loved ones, and we at Craig just want to support them in whatever way we can.”

“We tell our patients to go out and live life when they leave our hospital, to use community resources, get to know people, create social networks. But they can’t do that right now.”

but Cindy recognizes that it took continual therapy to get her to this point – and they aren’t done yet. Lauren was going to return to Craig in April for weekly outpatient therapy, and the family was looking into continuing

treatment for the contractures in her hands before COVID-19 began spreading throughout the U.S.; but all that stopped when the outbreak began. For the past six weeks, Cindy and her daughter haven’t left their house except for walks around their neighborhood that stand in for some of Lauren’s PT. Cindy says, “It’s hard to feel like life has stalled but we understand it is needed.” “We’re nervous about contracting COVID-19. My husband and I are in our 60’s, and if one of us were to be stricken with this and needed hospitalization, it would be very hard for the other one to do everything needed for Lauren,” Cindy says. “Lauren is also considered high risk, so limiting her exposure to the virus is critical.” The social changes have been an especially hard part of the COVID-19 outbreak. Cindy describes her daughter as a social butterfly; while Lauren has been using video calls to connect with her friends, she says it’s just not the same. Cindy had planned to go on a

Cindy Slack, a retired RN, serves as a fulltime caregiver to her daughter, Lauren, just outside Denver, Colo., with her husband. Lauren sustained a traumatic brain injury in a car accident in 2018 and has had a long journey of recovery that continues to this day. She has made much progress since her days in early rehabilitation at Craig Hospital when she arrived unable to speak or walk; now, Lauren often walks unassisted and is back to her talkative, social personality, but she still needs help with her daily routine. Before COVID-19, Cindy’s typical days with her daughter looked like weekly physical therapy appointments, participating in local community groups, social visits with friends and family, and keeping up with the medical care Lauren needs to continue her recovery. Lauren is doing well today, 15

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caregivers’ retreat this summer, but that was canceled along with other plans in the coming months to connect with friends and family. After going through a recovery like theirs, Cindy knows a strong support system is critical to their family. “Lauren’s done well with all the people who have been there to support us. All of the positive thoughts in the world, the compassion - they have been critical for us in this two-year journey, as much now as back then. We still need all that.” Cindy says her family is making the best of it. Though life may look drastically different, their family is enjoying spending more time together right now. They’ve had more time to work on some of Lauren’s goals, like becoming more independent in the kitchen, and the time at home has reminded them to be grateful and has given them the chance to have deeper, more meaningful conversations. “It keeps you aware of what you have. I have family in Detroit, and the city has been hard hit by the virus. Friends and acquaintances have passed away. When it hits you that close, you reach in for the gratitude,” Cindy says. “I look around and the dust on the floor isn’t bothering me today. We are healthy today. We are putting things in perspective.” Her advice for other caregivers: “Take time to breathe. Meditate if you can. One thing I’ve heard a lot from people at Craig is ‘You are where you’re supposed to be.’ I still have to keep telling myself. I feel like there is more I could be doing, but I have to stop myself and say, ‘I’m okay where I’m at.’ I can’t do everything. I’m where I need to be.” Not too far away, another caregiver, Ronda Romero, and her daughter Brittany have also experienced the impact of the stay-at-home order in Lafayette, Colo. When Brittany finished her inpatient rehabilitation at Craig Hospital in 2018 after she sustained a stroke during an emergency brain aneurysm surgery, she and her children moved in with her mother who became a caregiver to them all. When she first came home, Brittany struggled to communicate and take care of herself and her children, so Ronda and several others in their family stepped in to take care of her around the clock, turning Brittany in her bed every two hours overnight, helping her with activities of daily living each day, caring for her young baby and keeping her teenager in his school routines. Today, Brittany is speaking again, though still struggling with aphasia, and has taken over some of her selfcare. 16

and other occasions, but it’s done through video chats now. She also sometimes reaches out to Brittany’s Craig Hospital physical and occupational therapists for at-home exercises her daughter can do as well as texts with a caregiver she met during Brittany’s rehabilitation at Craig.

But the weight of social distancing has been heavy in their house, especially for Ronda who lost her husband of 38 years unexpectedly just weeks before Brittany’s stroke. The Coloradonative family has many family members who live nearby, but COVID-19 has halted their ability to visit in person. “It’s been a big change. Sometimes as a caregiver, it gets lonely, even though you know you’re doing this for all the right reasons. In my situation, I lost my husband, so I just think I felt every emotion. Frustrated, angry, happy, sad. And yet, when I see that Brittany is doing so much better, I’m grateful for that,” Ronda says. “Before, we went places, we did things. I do hope that opportunities can arise that we can explore things for Brittany to do. There are days she says, ‘I just want to go somewhere.’ And you try to redirect that request. I think she understands that there’s something very serious going on, that people are getting sick and dying from this. I don’t know if she understands how long this may carry on and how to deal with it.” In the meantime, Ronda has found ways for her family to enjoy connecting over dinner, games and simply sitting on the porch to talk, something they haven’t had as much time to do before this. They still celebrate birthdays

“I’ve reached out to her to see how they’re doing and to get ideas and see how I might be able to help Brittany. Puzzles, games, walking, we’re doing all those things,” Ronda says. “If anything, it’s nice to hear that they’re doing so well. It just kind of reinforces why we’re doing this labor of love.” Ronda’s advice for other caregivers: “Be patient. We’ve come so far, and once we get past this, we’ll continue to soar and get back to some normalcy. Hang in there. Love one another. We have our faith and we pray; we’re just thankful for every day and everyone.” If you are a caregiver and are looking for support, here are a few online resources that might be helpful right now: • Maintaining Your Emotional Wellbeing During COVID-19 • COVID-19: Spinal Cord and Brain Injury Tips • Craig Hospital Resource Library Craig Hospital’s Nurse Advice Line is also available to all to help provide advice and information for people across the country living with brain and/or spinal cord injuries as well as their families, caregivers and healthcare providers, regardless of whether or not they’ve ever been a patient at Craig. Craig Nurse Advice Line: 800-247-0257 or 303-789-8508

COVID-19 RESOURCE CENTER Thank you for the services you and your organizations are providing.

We are stronger when we learn and collaborate together. We are #ACMAstrong.

Member Advantage acmaweb.org/covid19

SEE YOUR REV CYCLE THROUGH A PATIENT’S EYES. THE RESULTS WILL AMAZE YOU. Clinical denials require focus and clinician intervention. With more than 130 physicians on staff, R1’s Physician Advisory Solutions can help. We support physicians and case management by navigating the regulatory environment and providing concurrent recommendations to increase billing compliance and reduce clinical denials.

Watch our Webinar: COVID-19: Regulatory and Payment Issues for Finance by Dr. Ronald Hirsch r1rcm.com/webinarseries

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A New Normal or Simply a Detour? COVID-19 and Case Management Ronald Hirsch, MD, FACP, CHCQM, CHRI Not a single segment of health care was untouched by the COVID-19 pandemic. Hospital volumes and revenue plummeted as elective surgery was cancelled en masse. Patients avoided seeing health care providers of all types for acute illnesses, including a distressing drop in volume of life-threatening diseases like strokes and heart attacks presenting to emergency departments. Instead of sitting by the bedside and meeting with patients, physician visits were converted to electronic visits. Caregivers who did enter hospital rooms were indistinguishable, covered head to toe in personal protective equipment. The Important Message from Medicare and the Medicare Outpatient Observation Notices were read to patients via telephone. A discharge plan was formulated without any direct face to face contact with the patient. Family members were not allowed at the bedside of their loved ones, intensifying the fear, uncertainty, and loneliness of a hospital stay. And many, many lives were lost, including thousands of health care workers around the world. But it was not all bad. Patients could sit in the comfort of their homes and have an appointment with their doctor, avoiding the long waits in the waiting room. Deductibles and coinsurance for many services were waived. All health care workers were recognized for their heroic work. Critical access hospitals were not bound by the 96hour rule. All long-term acute care admissions were to be paid at the LTACH rate with no site-neutral payment adjustments. Insurance companies waived prior authorization. The Centers for Medicare and Medicaid Services waived the utilization review conditions of participation. Acute care hospitals could provide sub-acute rehabilitation care to patients, albeit requiring more than a little extra paperwork, and get paid for that care.

COVID-19 also changed the way information on treatment of this novel illness was disseminated. While journals continued to accept submissions on case studies of patients with COVID-19, the timelines for review and publication were accelerated exponentially. The hydroxychloroquine craze was started by a (widely criticized) publication in a French journal with data on patients treated over a two-week period in early March. That study was published online a week later. Contrast that with HIV. The first case was reported in 1981, the first approved drug (AZT) was approved in 1987. AZT was prescribed as a capsule every 4 hours, around the clock, with patients told to set an alarm for their dose due during sleep, and it was soon learned that its effectiveness was shortlived as the virus quickly developed resistance. But the second approved drug, didanosine, was not approved for another 4 years. And, it should be noted, that almost 40 years later we still do not have a vaccine for HIV. In late March, as hospitals developed protocols to allocate the limited number of ventilators with the expected shortage, a critical care physician expressed concern about the early use of mechanical ventilation in patients with acute respiratory failure from COVID-19 in a YouTube video. Word spread there and on Twitter amongst a vibrant #MedTwitter community and the concept of high flow oxygen with prone positioning to treat clinically stable but hypoxic patients, later termed “happy hypoxemia,” was born. This discovery is likely the only reason the US did not have the critical issues with ventilators that were seen in Italy. The US had many patients who avoided mechanical ventilation because they were allowed to remain with low oxygen saturations and monitored closely instead of intubated “per protocol.” This avoided the need to activate those ventilator “rationing” protocols or convene ethics committees to make the difficult decisions choosing which patients were more “worthy.” But some things did not change. The TwoMidnight Rule, which is not part of the utilization review conditions of participation,

There is little question that the fact that two patients with the same illness receiving the same care from the same providers, but different payers could have a different admission status makes little sense, but until the system changes, we are obligated, both morally and legally, to follow the rules as they are written.

COVID-19 | SPECIAL ISSUE

was not waived. That seemingly contradictory guidance meant that admissions did not have to be reviewed as part of the utilization review plan, but you still had to get status determinations right, at least for Medicare patients. But this went beyond Medicare. Although insurance companies waived prior authorization, not one insurer stated that the physician’s decision to hospitalize a patient or admit them as inpatient was absolute. In fact, one payer stated on their COVID-19 update page that “although medical record claim reviews are suspended, we may request medical records retrospectively once the suspension is lifted.” The need to continue to follow the guidelines for hospitalization and status determination does make sense. While COVID-19 is a serious disease and many have lost their lives, it can also manifest with mild symptoms. Patients with COVID-19 can be sent home to selfmonitor, either with or without supplemental oxygen. The ability for physicians to prescribe home oxygen without meeting the strict national coverage determination has helped, as has the ability to declare such a patient as homebound so they may easily access home health care services. Many facilities have even provided patients with pulse oximeters and used telehealth to monitor the patient closely at home. When patients do need hospital care, their symptoms can vary greatly. Because some patients with COVID-19 deteriorate quickly, close monitoring is warranted. Oxygen desaturation with activity was found to be a good measure of risk and need for additional monitoring. While many such patients would require several days of monitoring, others may need only a limited period of in-hospital monitoring to determine if they will be stable to be discharged or require continued hospital care. Does their status matter? Isn’t it just about payment? Why shouldn’t we admit every COVID-19 patient as inpatient during a pandemic so doctors can concentrate on caring for patients? Even Congress recognized the seriousness of this disease by increasing the DRG weight for every Medicare COVID-19 inpatient admission by 20%. If only it was that easy. First, if one discounts the federal funds distributed as part of the CARES Act, there is no such thing as free money. The payment differential between an inpatient admission and an outpatient stay is substantial and neither the Medicare Trust Fund nor the 20

COLLABORATIVE CASE MANAGEMENT | ACMAWEB.ORG

commercial insurers are willing to pay providers money that was not “earned.” It should also be noted that while some areas such as New York City were hit especially hard, other areas saw some COVID-19 patients but were not overwhelmed. At the same time, the volume of elective admissions and admissions for other conditions dropped substantially,

Physicians who spent months wearing personal protective equipment all day long, with many isolating themselves from their family, unable to hug their partner or children, may have less tolerance for that insurance company medical director across the country who is second guessing their decisions. They will need our support, both emotionally and administratively.

leaving empty beds and less work for providers. And while one can argue about the morals of commercial insurance companies reporting billion-dollar profits, the fact is that during the pandemic millions of people lost their employer-sponsored health insurance and revenue from premiums to these insurers dropped substantially, leading them to ensure that what was paid out was appropriate. There is little question that the fact that two patients with the same illness receiving the same care from the same providers, but different payers could have a different admission status makes little sense, but until the system changes, we are obligated, both morally and legally, to follow the rules as they are written. Hospitals in many parts of the country are already starting to resume elective surgery and soon patients will once again feel more

comfortable coming to the hospital for their chest pain or abdominal pain. Slowly but surely volumes will return, and we will all need to get back to our tried and true processes, albeit while wearing a mask. The need to work with physicians on accurate documentation of their thought processes and the patient’s need for hospital care will be greater than ever as insurers look at the vast number of people who did not come to the hospital during the pandemic and “did just fine.” The need to cogently argue why a patient with pneumonia cannot be treated at home or as an outpatient with observation will be greater than ever. Physicians who spent months wearing personal protective equipment all day long, with many isolating themselves from their family, unable to hug their partner or children, may have less tolerance for that insurance company medical director across the country who is secondguessing their decisions. They will need our support, both emotionally and administratively. We may also face a hidden tsunami of patients who chose to avoid the hospital during the pandemic and then present weeks, months, or years later with new heart failure or advanced cancer who now require costly care. The fate of those who lost employer-sponsored insurance during the pandemic will also pose new challenges. For some, the health care exchanges can provide insurance with significant subsidies but navigating those options will be daunting for most. For patients who put off medically necessary but non-timesensitive surgery, such as joint replacement, their post-operative course may require more intensive and prolonged rehabilitation, leading to more challenges with payers. While attention to the social determinants of health has been increasing in the recent past, the disproportionate effects of COVID-19 on those with the greatest social needs will pose added urgency to address these needs, not only on an individual patient basis but by society in general. The devastating effects on residents of long-term care facilities will likely also lead to a reassessment of how such services can be provided in other settings. Case managers have joined their colleagues during the COVID-19 pandemic and acted heroically to continue to care for patients in the worst of circumstances. It is abundantly clear that they will help guide us out of this pandemic and continue to lead to make health care better for all in the future. I am proud to be part of that community.

Solving the Complex Problem of Unfunded Foreign Patients in American Hospitals for Over 40 Years During unprecedented COVID-19 travel restrictions and medical safety protocols, MedEscort continues to deliver on its unwavering commitment to superior service and patient care. Our knowledge, flexibility, and vast network of global resources allow us to work without interruption, to solve the problem of complex discharges for hospitals throughout the world. Extensive patient & family consultation and education

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MedEscort International has successfully repatriated over 6,000 patients to more than 100 countries www.medescort.com - Call Now 24/7 1-800-255-7182

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Flying Above the Medical Transport Challenges of a Global Pandemic By Julie Huber • Edited by: Craig Poliner • MedEscort International Inc. • Allentown, PA Under seemingly impossible COVID-19 global travel restrictions, MedEscort International provides hospitals and insurance providers with uninterrupted, highlyspecialized logistical assets that facilitate the discharge and repatriation of unfunded and undocumented patients.

borders. MedEscort worked closely with both the Peruvian and US governments along with the Peruvian Health Ministry to navigate the process with guidance from the CDC and the Health Ministry. MedEscort has successfully

MedEscort International is a diverse company offering unique medical transportation services domestically and internationally. As Aetna Insurance’s National network provider, MedEscort International continues to work through the complex COVID-19 pandemic, offering hospitals needed logistical assets to quickly and safely discharge patients and offer repatriation travel support services. This is in addition to serving organ transplant teams and the organ transplant community through their National Transplant Flight Group (NTFG).

MedEscort worked closely with both the Peruvian and US governments along with the Peruvian Health Ministry to navigate the process with guidance from the CDC and the Health Ministry.

COVID-19 has proved itself as a true contender for a world-class pandemic, by limiting resources as well as introducing new techniques for MedEscort International and National Transplant Flight Group. MedEscort was among the first companies to transport a COVID-19 positive American citizen home from Peru for medical care in March 2020. MedEscort followed all CDC guidelines for medical safety, utilized an isolation pod, and called on its vast global resources to successfully repatriate the patient. The patient was on vacation in Peru when the pandemic started and later became ill and was hospitalized with a diagnosis of COVID-19. MedEscort was contacted by the insurance company to collaborate with Peruvian and US governments to safely navigate a complex medical transportation process for the American patient, during a global travel lockdown with limited resources. The patient’s transportation plan was faced with many unique challenges in the Cusco region of Peru. Local authorities were extremely reluctant and fearful of transmitting COVID-19 from patients traveling across 22

provided the Peruvian Healthcare Ministry in the past with resources to return patients home and has a great working relationship for future cases as well. MedEscort International, using its global resources, secured an air ambulance with an isolation pod to transport the patient to the United States. The medical isolation pod had a dedicated, circulated air supply as not to contaminate the air in the aircraft putting the medical team and flight crew at risk of contracting COVID-19. The medical team consisted of a physician and a paramedic who

were able to monitor the patient’s vital signs through the isolation pod. As added protection, following CDC guidelines, the medical transport team also wore PPE for the duration of the flight. Even though the resources to transport the patient were secure and the countries’ governments were aligned to transport the patient, there were still multiple challenges to confront. In Peru, the complexity of the situation called for creative thinking and alternate procedures to get the patient home. Both governments collaborated and worked together to release the patient to the care of MedEscort to return home safely and securely. After arrival in the United States, the aircraft was quarantined and sanitized according to CDC guidelines and industry standards. The patient was admitted to a COVID unit in his hometown hospital and made a full recovery. MedEscort then logistically supported the safe return of staff and crew and reunited the family in the US. After the flight, the team was tested for COVID-19 and all staff and crew onboard tested negative for the virus. It was a successfully executed repatriated flight that created no cross-contamination or spread of the virus domestically or internationally. The process was then directed to Canada to repatriate a patient to his home in Guyana. Although he was not a COVID-19 patient, we still followed CDC guidelines and the guidelines of the Guyana Health Ministry to safely and successfully repatriate the patient. MedEscort consistently provides hospitals and patients the resources needed for successful repatriation, regardless of the situation. Pandemic or not, MedEscort is committed to being a resource and solution for the hospital and healthcare communities. MedEscort has successfully repatriated over 6,000 patients to more than 100 countries and continues to work through the transportation and logistics challenges of COVID-19. Navigating the challenges of COVID-19 has helped MedEscort find new and resourceful ways to

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get patients home safely, securely, and ethically. Each patient has a unique story that requires a unique process to repatriate following AMA guidelines for safe, complex discharges. There are normal obstacles and challenges, but new challenges have emerged due to COVID-19. Challenges like current events, flight restrictions, airport closures, travel bans, governmental closures, hospital restrictions, fear, and limited resources have created an environment for MedEscort to rise to the challenge and fulfill the needs of the hospitals, patients, and families. MedEscort works collaboratively with hospitals, social workers and case managers to help repatriate patients and reunite families as well as promote recovery and provide ongoing care. Not only does MedEscort Internationalâ&#x20AC;&#x2122;s expertise help the patients but it also provides support to the hospitals to minimize their financial losses.

MedEscort has successfully repatriated over 6,000 patients to more than 100 countries and continues to work through the transportation and logistics challenges of COVID-19. The National Transplant Flight Group (NTFG) supports transplant teams and the transplant community. NTFG has been met with the same number of challenges from COVID-19. Enhanced guidelines due to the pandemic have increased sanitization practices. All transport vehicles and aircraft are sanitized according to industry standards and CDC guidelines before and after each use and social

distancing is practiced for the safety of public health. Challenges like travel bans and increased safety measures create delays in supporting our transplant teams. Delays like these are costly to the success of a transplant procedure so NTFG takes all of the necessary precautions and planning logistics to minimize these delays. MedEscort International is cognizant of ever-changing current events and guidelines.

Our flexibility and adaptability have allowed us to not just fly patients but also become a guide and resource to hospitals, caseworkers and social workers during the most uncertain of times. If you would like to find out more about MedEscort International or speak directly to one of our medical directors for consult and navigation call 1-800-255-7182.

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Got Medicare? Get a No-Cost Test for COVID-19 By Seema Verma, Administrator, U.S. Centers for Medicare & Medicaid Services • Letter originally published for public dissemination in May If you have Medicare and want to be tested for coronavirus disease 2019 (COVID-19), the Trump Administration has good news. Medicare covers tests with no out-of-pocket costs. You can get tested in your home, doctor’s office, a local pharmacy or hospital, a nursing

When a vaccine for COVID-19 is developed, Medicare will cover that, too. home, or a drive-through site. Medicare does not require a doctor’s order for you to get tested. Testing is particularly important for older people and nursing home residents, who are often among the most vulnerable to COVID-19. Widespread access to testing is a critical precursor to a safe, gradual reopening of America. When a vaccine for COVID-19 is developed, Medicare will cover that, too. For Medicare beneficiaries who are homebound and can’t travel, Medicare will pay for a trained laboratory technician to come to your home or residential nursing home to collect a test sample. (This doesn’t apply to people in a skilled nursing facility on a shortterm stay under Medicare Part A, as the costs for this test, including sample collection, are already covered as part of the stay.) If you receive Medicare home health services, your home health nurse can collect a sample during a visit. Nurses working for rural health clinics and federally qualified health clinics also can collect samples in beneficiaries’ homes under certain conditions. Or you can go to a “parking lot” test site set up by a pharmacy, hospital, or other entity in your community. 24

We’re doing similar things in the Medicaid program, giving states flexibility to cover parking-lot tests as well as tests in beneficiaries’ homes and other community settings. We also implemented the Families First Medicaid eligibility option, which allows states to cover uninsured citizens’ testing costs with no cost-sharing. Individuals should contact their state Medicaid agency to apply for this coverage. Both Medicare and Medicaid cover serology or antibody tests for COVID-19. These tests can help identify who has been exposed to the virus. Medicare generally covers the entire cost of COVID-19 testing for beneficiaries with Original Medicare. If you’re enrolled in a Medicare Advantage health plan, your plan generally can’t charge you cost-sharing (including deductibles, copayments, and coinsurance) for COVID-19 tests and the administration of such tests. In addition, Medicare Advantage plans may not impose prior authorization or other utilization management requirements on the COVID-19 test or specified COVID-19 testingrelated services for the duration of the COVID-19 public health emergency. We have also required that private health issuers and employer group health plans cover COVID-19 testing, and certain related items and services, with no cost-sharing during the pandemic. This includes items and services that result in an order for, or administration of, a COVID-19 diagnostic test in a variety of medical settings, including urgent care visits, emergency room visits, and in-person or telehealth visits to the doctor’s office. From day one, President Trump has worked to ensure that cost is no barrier to being tested for COVID-19, and to make testing as widely and easily available as possible. As a result of these actions, we’ve seen a surge in testing among Medicare beneficiaries. Robust and widespread testing is of paramount importance as we begin easing back into normal life.

COVID-19 TOOLKIT TEXT FOR AMERICAN CASE MANAGEMENT ASSOCIATION VIRTUAL CONFERENCE The Centers for Medicare & Medicaid Services (CMS) is taking action to protect the health and safety of our nation’s patients and providers in the wake of the 2019 Coronavirus (COVID-19) outbreak. CMS has developed a Virtual Toolkit to help you stay informed on CMS and HHS materials available on the COVID-19. Please share these materials, bookmark the page, and check back often for the most up-to-date information. The toolkit can be found here: https://bit.ly/ covidpartnertoolkit Stakeholder calls on COVID-19 are also posted on this website along with the transcripts and recordings after the call takes place. More information can be found on the Podcasts and Transcripts page. For questions about partnering with CMS, contact Partnerships@cms.hhs.gov.

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Speedy patient discharge has never been more important. With Ensocare Transition, your team gains instant access to state-of-the-art software and one of the nationâ&#x20AC;&#x2122;s most robust post-acute provider networks.

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COVID-19 | SPECIAL ISSUE

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Speeding Up Discharge Communication with Post-Acute Providers in a Crisis By Mary Kay Thalken, RN, MBA As hospital resources grow strained due to the influx of patients suffering from the coronavirus, it’s absolutely essential to keep length of stay reasonable. When the determination is made that the patient is stable enough to transition to postacute care, that person must be transported out of the hospital quickly, thus freeing up the bed for the next incoming patient. Without efficient discharge processes, resources become strained beyond the breaking point. In many areas, this is already happening. In order to help alleviate the stress on hospitals, you need to be able to communicate with your post-acute care (PAC) providers quickly and efficiently. These insights aim to help hospital staff, case managers in particular, establish expedient and appropriate lines of communication with their post-acute providers. EMBRACE ELECTRONIC COMMUNICATION A fax or phone call-based discharge communication solution just doesn’t cut it in a crisis. Taking the time to fax all of a patient’s information ties up critical personnel and countless labor hours, as does attempting to reach prospective post-acute care providers on a landline. This increases costs during the COVID-19 pandemic. This scenario will only get worse as the lack of beds move “downstream,” so to speak, and starts to impact the post-acute providers dealing with additional patients convalescing in quarantined areas. The number of PAC facilities that can safely take on COVID-19positive patients is already extremely limited, and these facilities’ own resources will only grow more constrained as more and more patients move through the system. This will lead to a shortage of beds that can only be mitigated by a massive reduction in the time it takes to communicate with PACs. Instead of contacting two or three facilities, hospitals are faced with a scenario where they need to reach out to five, six, ten, etc., with

those numbers escalating further depending on the locale.

payer arrangement or some other agreement, will be crucial during this pandemic.

No hospital can afford to have their essential staff spend hours upon hours each day calling and faxing. It’s imperative that facilities invest in an electronic means of communication where they can send patient health information instantly. What’s more, that same system should enable quick response (30 minutes or

You already have a pretty good idea of what your current resources are. Reach out to your post-acute care providers now to see if their capabilities and capacities have changed, if they’re able to accept COVID-19 cases, and what their protocols are if so. Better yet: check with your vendor to see if, like Ensocare, your discharge software has a feature that lets you instantly determine if a given post-acute facility will accept COVID-19 patients, which saves you yet another step!

A fax or phone call-based discharge communication solution just doesn’t cut it in a crisis. less) of a ‘Yes’ or ‘No’ answer as to whether the PAC can accept the patient. One additional benefit of this type of E-system is its utilization of the cloud, which enables team members to access the discharge software safely and securely, wherever they are, on a mobile or desktop device. Not only can this save critical time by not requiring team members to travel to specific work stations to initiate a discharge referral, but it also limits those remote workers’ potential exposure to the virus, since they don’t necessarily have to be in the hospital to oversee patient transitions of care.

Now is the time to harness and engage your network in order to ensure the patients being discharged will be taken care of appropriately. And if you don’t have a narrow network? Start trying to come up with one, fast. CONSIDER EXPANDING YOUR NARROW NETWORK In these extraordinary times, it also might be worthwhile to explore the expansion of your existing narrow network. I don’t mean that you should cut corners when it comes to discharging patients. However, in the interest of freeing up beds and getting COVID-19 patients to facilities where they’ll be properly taken care of, it might be worth considering the creation of a new narrow network. This could be an expansion of a current network or something else entirely. Basically, you would be planning which facilities are able to take on your patients if your typical go-to providers are full or unresponsive.

HARNESS YOUR NARROW NETWORK

We might be witnessing the creation of entirely new facilities set up in this emergency for the sole purpose of helping patients recover from COVID-19. As these come online, consider plugging them into your quick lists of preferred providers so that you can quickly discharge patients as necessary.

Your narrow network, the PAC facilities you’ve partnered with as part of an ACO, a

It’s also important to note that, as you move to electronic communication, you’ll want a

COVID-19 | SPECIAL ISSUE

post-acute referral vendor who’s able to create profiles on the fly as they arise. If you don’t already have this capability, or aren’t sure if you do, please contact your current vendor as this is a must-have in an emergency scenario where new, critical facilities are being set up in real-time. COMMUNICATE WITH YOUR ENTIRE NETWORK We’ve heard from more than one hospital that has expressed a need to send communication about coronavirus patients to their entire post-acute network. Thankfully, Ensocare is more than equipped to provide this service, and we were able to work together with these hospital systems to ensure such a communication was deployed through our Transition software. We would advise considering this kind of network-wide transmission yourself if you haven’t done so already. If you’re experiencing a sharp uptick in COVID-19 cases, or anything about your typical discharge patterns is about to change, it’s in your best interest to let this be known to all of your potential post-acute partners at once. In addition, this will enable you to include questions within that communication about the PACs’ capabilities if they haven’t shared the information with you yet. This could be just the prompt they need to explain what they’ve done to prepare for the rapid influx of patients. Being proactive about these communications can help you plan as you deal with the ongoing pandemic.

COLLABORATIVE CASE MANAGEMENT | ACMAWEB.ORG

ESTABLISH FOLLOW-UP PARAMETERS WITH CASE MANAGERS Finally, you should have protocols in place for contacting patients and their post-acute care providers after they’ve been discharged from your facility. The last thing you want in this scenario, where beds and personnel are at a premium, is to have a patient you discharged be readmitted to your hospital. If this happens, it can make an already precarious situation even more dangerous.

Just as important as having software in place to establish electronic communications with PACs is having staff capable of using that software and standardizing your workflow.

TRAIN NEW TEAM MEMBERS ON YOUR SOFTWARE Just as important as having software in place to establish electronic communications with PACs is having staff capable of using that software and standardizing your workflow. Have your regular users immediately start to train anyone who could conceivably take on the responsibility of helping to discharge patients. This could even help you free up nurses typically responsible for the administrative tasks associated with post-acute care referrals to do more clinical work while non-clinical staff take over discharge communication. I’d encourage you to think about who could take on the additional duty, particularly if your clinicians can be better deployed elsewhere. 28

Having case managers check in with PACs, patients and patients’ family members at regular intervals can help you identify signs that the patient may be relapsing. In those situations, you can connect them with the prescriptions, medical devices, clinical experts and other resources they would need to prevent a readmission. If you haven’t done so already, figure out follow-up parameters and be willing to adjust quickly as patterns begin to emerge. A BRAVE NEW WORLD We’re all coming to terms with the impact the coronavirus is having on the healthcare

system. But one step we can’t ignore is the essential communication and hand-off that must occur between acute and post-acute care providers. Hopefully, the above ideas will help you free up beds, better manage and even decrease length of stay, and assist the highest number of patients in the best way possible. And if you need any help with anything or have any questions about the topics we’ve covered, please don’t hesitate to reach out to us. Thank you for everything you do during this troubling time. Interested in learning more about speeding up patient discharge, electronic communication between acute and post-acute providers, or Ensocare’s Transitions of Care solutions? Learn more and schedule a 30-minute consultation with our Chief Clinical Officer! Visit Ensocare.com/ACMA to get started! AUTHOR BIO: Mary Kay Thalken, RN, MBA mthalken@ensocare.com Mary Kay Thalken is the Chief Clinical Officer of Ensocare. She provides executive, operational and clinical expertise to help hospitals better manage patient care transitions and achieve financial savings through reduced length of stay and preventable readmissions. She has held significant leadership roles for health systems in Georgia and Nebraska over the last 25 years, including roles as Chief Nursing Executive, Chief Operating Officer and Corporate Quality & Innovation Executive for CHI Alegent Health System in Omaha, Nebraska. She has presented on the topics of improving quality, patient flow and throughput at various industry conferences and webinars. She obtained her Master of Business Administration degree from the University of Nebraska Omaha and an undergraduate degree from the College of Saint Mary. She is a member of the American College of Healthcare Executives, the American Organization of Nurse Executives and the American Case Management Association. Ensocare 13808 F Street • Omaha, NE 68137-1102 Ph: (402) 758-2635 www.ensocare.com

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2300 Dulaney Valley Rd | Timonium, Maryland 21093 | stellamaris.org

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Adapting and Growing in the Face of a Pandemic A Senior Health Care Facility’s Lessons Learned By Regina Figueroa, LNHA, MHSA Times of crisis – and certainly the COVID-19 pandemic qualifies – are unique moments for any organization, especially for those in an industry such as ours, caring for the most vulnerable. These times serve as a test of your mission and values. As the Chief Administrative Officer of the largest comprehensive senior community in central Maryland, I can say Stella Maris has adapted to the changing landscape swiftly and efficiently— safeguarding the families that we serve, and supporting our clinical and lay staff who deliver care with dignity and compassion.

Over these past months, we have learned some important lessons from “fighting on the COVID-19 frontlines.” 1 Reaffirm Your Networks. Your relationships with your local and state representatives will be key during times like these. The Maryland Hospital Association, Emergency Management Association, the State House, the Maryland Department of Health, the various senior living associations—all came together to assist, on multiple levels, with sharing updates, providing guidance and giving the comradery of support. Stella Maris’ relationship with Mercy Medical Center allowed us to secure resources from signage to screening services so COVID-19 screening could occur twice daily in areas where patients or staff tested positive. In difficult times, always look to “who’s in your backyard” for support. 2 Don’t Buckle Under Pressure. The earliest reports of COVID-19 in the U.S. focused on a nursing home, Life Care Center in Washington State, immediately placing senior facilities nationwide under media scrutiny. In response, focus on your strengths. In our case, Stella Maris has a strong reputation for dealing with the most difficult health issues, from Alzheimer’s to MRSA/infections, post-traumatic injury rehabilitation and end of life hospice. Caring for infectious and clinically acute patients is part of the daily mission, and in that sense, response to COVID-19 or other disease is no different. 3 Go “Above and Beyond.” Stella Maris secured the first emergency CON (Certificate of Need) for two special COVID-19 units that are separate from our

main nursing home, which the Health Service Cost Review Commission (HSCRC) called “a model for Maryland.”

Your relationships with your local and state representatives will be key during times like these. 4 Celebrate Your Workforce. During difficult times, top executives are often the most visible, appearing in interviews, specially crafted videos, town halls and social media. However, not all those who make key contributions receive attention. To bolster both morale and performance, it’s especially important to make sure that all employees receive acknowledgement for their efforts. The nursing aides, supply chain managers, delivery and cleaning staff, etc., become your “goodwill ambassadors” to the community, so it is important to foster their goodwill.

5 Harness Your Strength. At Stella Maris, we are continually investing to better serve a growing need. As the Baby Boomer generation ages, we have increased our capacity and range of services to meet that need, and our Home Health Care program is an example of that. In this time of pandemic, as so many self-isolate, the need for home healthcare services has increased. The caseload of Stella Maris’ Home Health Care business line has not only grown in volume but carried us through times when we could not admit into the skilled nursing facility. 6 Embrace Technology. Stella Maris was the first facility in the region to close to visitors as a precaution but was able to provide communication with families using telemedicine. Either with an app or just your computer, a visit or consultation can still occur. Industry trends indicate telemedicine will continue to play an important role between providers, patients and their families, and we are seeing this firsthand. Additionally, the billing process remains the same for the provider and it has become quite popular. 7 Focus on the Details. While basics like washing hands and using sanitizers have always been paramount as a safeguard for residents, addressing high touch areas is even more vital during the pandemic. Doorknobs, telephones, computers, medical equipment, charts, pens/pencils, shared bathrooms--these are areas that we as an industry will redesign to

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change the workflow and enable touch-free solutions. Less touching equals less chance the virus or any other germs can spread.

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aforementioned professional, civic, business, and government networks to provide the supplies needed to protect both residents and staff.

8 Give the Gift of Space. Social Distancing in the workplace has been challenging, but not impossible. In healthcare we have the nursing stations, charting rooms, small office areas, visitor lobby areas and conference rooms just to name a few locations that have now been empty. As an industry, we must continue the small gatherings of 1-5 people in these areas and embrace teleworking for eligible positions.

10 Over Communicate. We implemented new ways to update our audiences on positive coronavirus cases, recoveries and deaths. We embraced the use of email, mail, Facetime, WebEx, company website, family portals and the telephone information line. We made sure that the information was disseminated via multiple platforms to ensure our message was delivered

9 Safeguard Your Supply Chain. In senior living healthcare, PPE like N95 masks and gowns are used, but typically not in massive quantities. The global pandemic quickly dried up the usual avenues for securing needed PPE. One must become innovative in finding ways to secure the necessary supplies; at Stella Maris, this meant implementing a special program to secure donations, overseas contributions, tapping into the

11 Stay True to the Mission. While dealing with a pandemic is anything but “business as usual,” it is important to make sure, for the residents, their families and staff, that it appears to be just that. The crisis may be great, but the goals remain the same as during “normal times”—to provide quality care in a compassionate setting. To continue to grow—even now, we prepare to open a new, state-of-the-art Rehabilitation Center.

COVID-19 did not come with its own playbook. Every crisis is different, requiring a specifically tailored response. But the mission remains the same. A dedication to excellence on behalf of our teammates and all those we serve. Our commitment to quality and compassionate care. To innovate, educate, connect and communicate. To remove the obstacles that may prevent us from achieving our goals for the betterment of all. AUTHOR BIO: Regina Figueroa, LNHA, MHSA is currently the Chief Administrative Officer of Stella Maris, the largest skilled nursing facility in central Maryland with 412 beds, including a sub-acute rehabilitation center and a hospice unit. The campus also includes an adult day care center, a home health care business, private duty aides and a 200 apartment senior living complex. Mrs. Figueroa has more than 20 years of experience in operating and ensuring compliance of nursing and care services with established state and federal regulations. To learn more about Stella Maris Inc., go to www. stellamaris.org.

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Home Care Rapidly Adapts to Impacts of COVID-19 Shining A Light on Importance of Care at Home By Lakelyn Hogan, MA, MBA & LaNita Knoke, RN, BS, CMCN, CRPF Staying at home has been designated as one of the safest ways for people to reduce their exposure to COVID-19. This is especially true for the most vulnerable, including the older adult population. The home care industry has been working to keep aging adults safe and healthy at home for decades. However, home care services have often been overlooked by the health care system or confused with home health services. Home care is provided by trained professionals with customized plans of care to assist with a range of needs including personal care, medication administration and management, memory care support and more. During this time, when home is the safest place to be, home care has been deemed an essential service an important factor in keeping seniors out of the hospital and protected from the exposure of COVID-19, and other infectious disease. While the goal of home care has remained the same during this pandemic, the way services are offered have been adapted. This article highlights the rapid response of a large home care organization, Home Instead Senior Care® and suggestions for best practice for the home care industry.

this information and created helpful resources, that was effectively disseminated to local franchise offices. This allowed offices to focus on their team and client safety, along with the local health department guidelines. This taskforce identified a need for network exposure support and developed an exposure triage team. This team supported the network as they worked through their potential and confirmed exposures impacting their business, CAREGivers, clients and clients’ families. The exposure team also identified the need for mental health resources to support the network in their grief and loss. REINFORCED TRAINING The ability of the Home Instead Senior Care network to reinforce employee training was important and it was accomplished quickly. Education included standard precautions, hand washings, infectious disease control and proper use of personal protective equipment (PPE). Verification of completed education from franchise offices ensured consistency across the network. ADAPTED LOCAL OPERATIONS

Long before COVID-19, Home Instead Senior Care had best practices in place for the health and safety of all stakeholders including older adults, professional CAREGiversSM and office staff. These precautions were originally developed to reduce the spread of illness, especially during influenza season. This pandemic highlighted the need for Home Instead Senior Care to reinforce and build upon these best practices in the following areas.

Operational practices at the local franchise level were also adapted. While in most cases, the essential home care services continued in the home, technology was utilized for additional operational efficiencies. Instead of in-person care consultations and quality assurance visits, virtual interactions took place. Fortunately, virtual technology had already been deployed in some clients’ homes and this was utilized as an alternative or enhancement to their current care.

NATION-WIDE SUPPORT

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The Home Instead Senior Care Global Headquarters assembled a COVID-19 response team that shifted its focus entirely on the pandemic. This cross-functional team worked to understand the everchanging information provided by the World Health Organization and Centers for Disease Control. They compiled

Home Instead Senior Care has always been dedicated to supporting family caregivers but noticed the added strain they were experiencing as a result of COVID-19. To provide information and support, Home Instead Senior Care created a COVID-19 resource page with articles

During this time, when home is the safest place to be, home care has been deemed an essential service, an important factor in keeping seniors out of the hospital and protected from the exposure of COVID-19, and other infectious disease.

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to help family caregivers such as “5 Important Questions to Ask Seniors During Social Distancing” and “7 Ways to Keep Seniors Engaged During COVID-19.” A Caregiving During COVID-19 Facebook Live Series was also held on topics to help caregivers navigate their role during this challenging time. Topics included social isolation, technology and caregiving, and dementia care.

As Home Instead Senior Care moved through the pandemic, key elements of the business were continually analyzed to improve upon best practices. The lessons learned from that analysis supported the changes made in the organization’s approach to caring for the nation’s older adults. The key elements of learning are included below:

OFFERED PROFESSIONAL EDUCATION

CRITICAL LEARNINGS FOR HOME CARE:

There was also a need that Home Instead Senior Care saw for professional education during this time. In partnership with the American Society on Aging, a series of webinars were offered with free CE credit. Topics included:

• Assemble a cross-functional situational task force for these types of circumstances

• Technology and Caregiving – Recorded April 1, 2020. CEs are available until June 1, 2020.

• Embrace technology and utilize virtual communication with all stakeholders • Regularly update protection procedures, training and practices

• Loneliness & Aging: The Other Epidemic – Recorded April 27, 2020. CE credits are available until June 27, 2020

• Continually monitor the necessary tools and materials for providing care in these types of circumstances

• Preparing for Loss: Death, Dying and Grieving – Recorded May 6, 2020. CE credits are available until July 6, 2020

• Keep network informed on infection control procedures and new potential viruses that could become a threat

ABOUT HOME INSTEAD SENIOR CARE Founded in 1994 in Omaha, Nebraska, the Home Instead Senior Care® franchise network provides personalized care, support and education to enhance the lives of aging adults and their families. Today, the network is the world’s leading provider of in-home care services for seniors, with more than 1,100 independently owned and operated franchises that provide more than 80 million hours of care annually throughout the United States and 13 other countries. Home Instead Senior Care franchise owners partner with clients and their family members to help meet varied individual needs. AUTHORS: Lakelyn Hogan, MA, MBA, Gerontologist and Caregiver Advocate, Home Instead Senior Care & LaNita Knoke, RN, BS, CMCN, CRPF, Healthcare Strategist, Home Instead Senior Care Author Contact Information: P: 402.498.4466 Emails: lakelynhogan@homeinsteadinc.com & lanita.knoke@homeinsteadinc.com Website: www.HomeInstead.com

ACM Certification Review Workshop TWO-PART WEBINAR SERIES

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Utilization Management is Broken. Now is the Time to Rebuild. By Joan Butters, Chief Executive Officer of XSOLIS Friction…Abrasion. Denial…Appeal. Cost… Cost Center. None of these words sound positive, do they? Yet they’ve often described utilization management between payers and providers. Denials and appeals became a status quo that costs hundreds of millions of dollars per year while increasing the discord between payer and provider which often trickles down to the patient. Clinical expertise has slowly become all but cut out of the review process, which was subjective, administrative and tailored to a tool, not tailored to the patient. The costs mount, the tension increases, the system buckles. In the wake of COVID-19, this status quo should not be allowed to stand. What I’ve seen over the past few months has been heartening: a groundswell of collaboration between providers and payers, new ideas bearing fruit, a realization that the patient is more important than paperwork. We shouldn’t go back to the way things were. Today, we should set forth to rebuild utilization management through three major steps: restoring clinical reliance, rethinking the administrative process, and reframing payerprovider partnerships. RESTORE CLINICAL RELIANCE Utilization management (UM) was intended to be a complex clinical judgment, yet it was not always treated that way: nurses and physicians are now reliant on traditional criteria sets rather than their clinical expertise, which leads both hospitals and health systems to dispute cases based on the criteria, not on the clinical merit of the case. This is changing. I’ve seen leaders nationwide, from CEOs to CFOs to VPs and directors, take a closer look at utilization management as a clinicallycentered value add for their organizations. They realize that they have hired the right nurses and physicians and want to put them “back in the driver’s seat” across the review process: initial determinations, peer-to-peer

reviews and beyond. And as we add technology to the mix, we can remove the administrative quicksand that keeps staff from doing their best work. With technology and teams aligned, reshaping what utilization review can achieve – lower costs, appropriate care, optimal outcomes – is within view. RETHINK THE PROCESS Technology has so much to offer healthcare, both by reducing complexity and making it easier for clinicians to work at the top of their licenses. Correspondingly, forward-thinking leaders now have technologies like artificial intelligence and its subdomains (machine learning, deep learning, natural language processing and the like) in their headlights, bringing them to bear on process automation, risk stratification and more. Until the past few years, UM has not received the same level of attention and innovation as other parts of the continuum. However, that is rapidly changing. There are now solutions tailored to UM-specific needs and activities across the marketplace – and they set a new, positive tone for the profession. Prominent leaders across the nation have already adopted novel approaches to their utilization management processes, either by adopting technologies that make their staff more efficient, effective and clinically focused, or by harnessing automation that can reduce the administrative burden for their staff. I see this trend accelerating rapidly and paving the way for more direct, transparent relationships between payers and providers. REFRAME PAYER-PROVIDER PARTNERSHIPS As with healthcare at large, utilization management should be centered on the human: patient, member, loved one, friend, partner. Are they the recipient of unintended cost overruns or impacted financially by disputed claims? Payers and providers are both guardians for the people and I view it

as our duty as an industry to get patient care right for them; our secondary duty is to reduce the administrative burden and complexity that stifle care delivery and increase costs that get passed along to consumers. As an entrepreneur, my focus is on that second duty. During the course of the COVID-19 pandemic, several of our client organizations – United Health Services, Chesapeake Regional Medical Center, Citizens Medical Center – have adopted the same approach as Covenant Health, an integrated health system based in Knoxville, TN, which is using our technology platform to connect them directly with a major national payer for utilization review activities. These hospitals and the payer have cut out the faxing/phone tag/lack of clinical information conundrum by using this platform to escalate cases directly to the payer, who then can undertake real-time case reviews and approvals for members as well as view the admit and discharge info that has been invaluable during the pandemic. To quote a leader at the payer, “the days of having adversarial relationships between payers and providers has got to end.” By rethinking and rebuilding what utilization review should be, these hospitals are leading a charge that will reshape payer-provider relations. REBUILDING, TOGETHER As the move towards value-based, human-centered care accelerates, providerpayer trust must increase. Utilization review that is clinically centered, technology-driven and collaborative acts as a bridge of trust between payer and provider. With objectivity in the process, results can be quantified, outcomes can be tailored, and relationships can be mended. As a healthcare leader, I ask you to find a new way forward for your people, processes, and partnerships, within utilization management and without. Together, we can build a smarter future for healthcare.

Tackling COVID-19, Together XSOLIS is dedicated to helping your organization and staff thrive during this crisis. Thank you for all you do.

Visit our website xsolis.com/covid-19 for resources to help you during this time of crisis.

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TIRR MEMORIAL HERMANN AND THE MEMORIAL HERMANN REHABILITATION NETWORK

Phil Eaton: Road to Recovery As a high school principal, Phil Eaton is constantly on the go… football games, staff meetings and other activities fill his calendar. In March 2020, he was admitted to Memorial Hermann The Woodlands Medical Center and diagnosed with COVID-19. His condition became serious, and he spent 21 days on a ventilator.

“In conditions like COVID-19, the patient has had a significant change in their functional status or their ability to move around and do their daily activities…” After being discharged from acute care, Phil was extremely weak and demonstrated some changes in his memory and ability to process and organize his thoughts. To further his recovery, his healthcare team recommended he transition to inpatient rehabilitation at TIRR Memorial Hermann The Woodlands for customized rehabilitation for patients who have recovered from COVID-19. “You’ve got to be so careful with this virus,” said Phil, who was hospitalized for a total of 51 days. “I am so thankful for TIRR and the

Memorial Hermann Health System.” “In conditions like COVID-19, the patient has had a significant change in their functional status or their ability to move around and do their daily activities,” said Dr. P. Jacob Joseph, Physical Medicine and Rehab (PM&R) Specialist and Phil’s attending physician at TIRR. “Patients also could experience difficulty with their cognition and could benefit from

coming to inpatient rehabilitation directly from acute care.” “When Phil initially arrived he was having some memory problems, and it was challenging for him to stay on topic when we were talking. Phil’s thoughts weren’t organized – he did a lot of jumping around. For his profession, we knew that would be a problem and began addressing those issues,” said his speech

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CHALLENGES FOLLOWING COVID-19 EFFECT, IMPAIRMENT

LIMITATIONS

Long-term ventilator use

Cognitive impairments due to anoxia/hypoxia (reduced oxygen to the brain)

Decision-making, critical thinking, judgment

Positioning during ventilation management

Compromised skin integrity

Functional mobility which effects sitting, transferring and walking

Prolonged ICU stay

ICU acquired weakness or post Decision-making, critical intensive care syndrome thinking, judgment

Limited therapy in acute care setting

Peripheral nerve injuries

ICU delirium causing cognitive impairments

Cognitive dysfunction

Patients are needing increased physical, occupational and speech language pathology therapies

Functional mobility which effects sitting, transferring and walking

WE HAVE A DEDICATED INTERDISCIPLINARY TEAM THAT MAY INCLUDE: • Physiatrists (rehabilitation doctors)

• Rehabilitation nurses

• Medical Consultants, including primary care internists, psychiatrists, wound care specialists, OB-GYN, pain management specialists, urologists, gastroenterologists, otolaryngologists

• Patient care assistants

• Hospitalists

• Chaplain

• Neuropsychologists and psychologists

• Social workers

• Physical therapists

• Case managers

• Occupational therapists

• Clinical pharmacists

• Speech-language pathologists

• Clinical nutritionists

language therapist Nicole Wren, M.A., CCCSLP. Nicole incorporated tasks that could relate to Phil’s work as part of his therapy. For example, she had him plan out a morning school announcement given a list of criteria and then practice saying his announcement out loud. He also wanted to write thank-you letters, so she used this as a treatment task that targeted each of his speech therapy goals - organization, planning, and attention. Claire Shaver, PT, DPT his physical therapist saw marked improvement in Phil from the time he arrived in inpatient care to the day he left nearly three weeks later. “Initially, he would need a 5 or 10 minute break when simply going from sitting to standing,” said Claire. “We took really small steps because he needed to conserve his breath and energy. It was a big day when he was able to walk to the bathroom 40

• Neurologic music therapists • Therapeutic recreational therapists • Respiratory therapists

and later down the hallway. He made weekly advancements and ultimately was able to walk 1000 feet.” One of the first things his occupational therapist, Katie Pecot, OTR, did was learn what Phil liked to do away from his job. “He enjoys golfing and basketball, so we used that as part of his therapy to build muscle mass/strength, endurance, respiratory capacity, and high-level cognition,” said Katie. “I spent sessions focused on standing tolerance and functional endurance while typing, playing basketball, shaving, managing clothes and engaging in games that involved problem solving.” “They have been so good to me,” said Phil as he was leaving TIRR. ”I feel great. I can stand, walk and even dance! Their dedication to their jobs, professionalism, kindness and ability to meet me where I was makes me want to cry!”

TIRR MEMORIAL HERMANN AND THE MEMORIAL HERMANN REHABILITATION NETWORK TIRR Memorial Hermann 1333 Moursund Houston, TX 77030 Inpatient, Outpatient Clinic, Neurological Sleep, Imaging, Research Center TIRR Memorial Hermann Outpatient Rehabilitation at the Kirby Glen Center 2455 S. Braeswood Houston, TX 77030 Outpatient, Pediatrics TIRR Memorial Hermann Outpatient Rehabilitation at Memorial City 10125 Katy Freeway, Suite 108 Houston, TX 77024 Outpatient TIRR Memorial Hermann-Greater Heights 1635 North Loop West Houston, TX 77008 Inpatient, Outpatient, Pediatrics TIRR Memorial Hermann Outpatient Rehabilitation at Sugar Land 1111 Highway 6, Suite 195 Sugar Land, TX 77478 Outpatient, Pediatrics TIRR Memorial Hermann Outpatient Rehabilitation at West University 2909 West Holcombe Blvd. Houston, TX 77025 Outpatient TIRR Memorial Hermann-The Woodlands 9250 Pinecroft Drive The Woodlands, TX 77380 Inpatient 920 Medical Plaza Dr., Suite 270 The Woodlands, TX 77380 Outpatient, Pediatrics Memorial Hermann Rehabilitation Hospital-Katy 21720 Kingsland Blvd., Suite 102 Katy, TX 77450 Inpatient, Outpatient, Pediatric Outpatient, Sleep Lab, Wound Care and Hyperbarics, Imaging Memorial Hermann Southeast 11800 Astoria Blvd. Houston, TX 77089 Inpatient Memorial Hermann Southwest 7600 Beechnut Houston, TX 77074 Inpatient Memorial Hermann-Texas Medical Center 6411 Fannin, Jones Pavilion, 4th floor Houston, TX 77030 Inpatient

Customized Rehabilitation for Post COVID-19 Patients TIRR Memorial Hermann and The Memorial Hermann Rehabilitation Network are leading the charge in the functional rehabilitation of individuals who had COVID-19 and are no longer testing positive. Our evidence-based interventions allow patients to go beyond the clinical setting, providing them with the opportunity to participate in important life roles in the home, work, volunteer and community environments. Our goal is to help patients achieve and maintain a maximum level of independent functioning and improved quality of life, after COVID-19. Due to the nature of the virus, many patients experience difficulty breathing, even after the virus has left the body. Patients that require ventilators are at an even higher risk of longterm effects. Individuals who had COVID-19, may also experience muscular atrophy and physical weakness, a loss of balance and coordination, even cognitive issues due to reduced oxygen to the brain. The effects and impairments each person, recovering after COVID-19, faces are similar yet very unique. Therefore, our team customizes therapy and care for the individual based on their personal goals. Other complications include: • Deconditioning • Lack of coordination • Muscular atrophy and physical weakness

• Balance dysfunction and coordination • Breathing difficulties • Swallowing dysfunction and dysphagia

The COVID-19 rehabilitation program may maximize patient outcomes by providing: • A comprehensive evaluation of functional status by an interdisciplinary team • Therapeutic exercise and functional activity programs tailored to the patient’s condition and needs • A continuum of care that may include: inpatient rehabilitation, outpatient rehabilitation, outpatient medical clinic and a community wellness program • Extensive education and support to ensure patients and families have the resources and knowledge needed for successful integration back into the home and community Services: • Inpatient rehabilitation • Outpatient rehabilitation

• Challenge Program (including return to work, school and independence) • Outpatient Medical Clinic

Family Care thanks all Clinicians, Discharge Planners, Case Managers, and Healthcare Heroes who continue to provide care to patients during the pandemic.

Family Care is a full-service home care agency, providing Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Language Pathology, Medical Social Work, and Home Health Aide Services. PROGRAMS/SERVICES OFFERED -

Heart to Heart Cardiac Program (CHF, COPD) Advanced Wound Care Program – WCC nurses in all offices Wound Vacuum Assisted Closure Behavioral Health Program Pediatric / Maternal Child Health Program Post-Surgical Care Rehabilitation Therapy (PT, OT, SLP & MSW) Diabetes Management

Medication Administration Nutrition Management IV Therapy Benefits counselors on staff to assist with Medicaid redetermination / insurance issues Accepts all insurances including Medicaid / Medicare / all private insurances / ABI : TBI waivers, autism waivers, Katie Beckett, selfpay Telehealth visits by in-house APRN

JCAHO accredited since 1999 Members of Patient Ping Connecticut Network Members of Qualidigm’s Reducing Re-Admissions Task Force

To refer a patient, contact our Intake Department 24/7, 365 days a year at: Phone: 1-800-946-6331

Fax: 1-203-380-3229

Weekend and “after-hour” referrals are handled by our “On-Call” Intake Coordinator. If your call is not returned in a timely manner, contact our “On-Call” Intake Coordinator via cell phone at: 1-203-249-4194 Woodbridge 1764 Litchfield Turnpike Woodbridge, CT 06525

Stratford 999 Oronoque Lane Stratford, CT 06614

Norwalk 9 Mott Avenue Norwalk, CT 06850

Meriden/Waterbury 1371 East Main Street Meriden, CT 06850

Visit us on the web at: http://www.familycarevn.com Contact us via email at: customerservice@familycarevn.com Like us on Facebook at: www.facebook.com/FamilyCareVisitingNurse

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How ADT Health Helps Seniors Stay Safe and Healthy This Summer By Andrew Droney, Senior Director of ADT Health It’s no secret that the demographic hardest hit during the COVID epidemic has been seniors, and as states begin to lift shelter-in-place restrictions, it’s important that seniors take extra steps to help ensure they remain safe and healthy both at home and as they venture out. To help give seniors (and their loved ones!) greater peace-of-mind this summer both at home and on the go, Andrew Droney, Senior Director of ADT Health, shares some simple tips on how to stay healthy and safe. From simple exercises to having a Personal Emergency Response System (PERS), there are many things seniors can do to maintain a safe, active and independent lifestyle on their terms. STAY ACTIVE, SAFELY! Exercise is a great way to improve breathing, achieve better balance and lift mood. That’s why it’s important for seniors to remain active while minimizing the possibility of injury. Before starting any physical activity, people should consult their physician to make sure it’s okay and take it slow and if possible, exercise with a partner for support and help should they need it. Taking walks outside are great for keeping bodies moving while following social distance guidelines. It doesn’t have to be far—even walking around the backyard or doing light aerobics at home is an excellent way to safely remain active. STAY HYDRATED Increased temperatures and humidity during the summer means bodies are heating up as well. According to the American Heart Association, drinking water and staying hydrated are essential to keeping the heart healthy and the muscles working effectively. Dehydration can lead to physical ailments such as heat exhaustion, heatstroke and other serious physical ailments. TOOLS TO AVOID FALLS This might sound obvious, but it’s a serious concern. Every year, two million older

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Americans go to the emergency room due to fall-related injuries, according to the National Institute on Aging. Heat-related ailments like heat exhaustion and stroke can also lead to dizziness and lightheadedness. Prevention is key to reducing the chances of serious bodily trauma. Seniors should focus on exercises that build strength, improve balance and control muscles. Poor vision can also lead to accidents—remember to get your vision checked yearly and ensure access to up-todate prescription lenses or contacts! KNOW THE SIGNS Knowing the symptoms of heat overexposure ensures seniors can get help quickly if they’re affected. Below are key signs of heat exhaustion: • Heavy sweating • Faintness / Dizziness • Fatigue • Muscle Cramps • Nausea • Cool, moist skin when in the heat • Low blood pressure

Experience any of these during a hot day? Stop activity to rest, move to a cooler place and drink water. If symptoms don’t improve, it’s time to call a doctor. And to provide additional peace of mind, consider ADT’s Health Medical Solutions, also known as Personal Emergency Response Systems (PERS). The wearable medical alert system offers cost-effective ways to maintain independence while staying safe and connected to caretakers and family members. They allow for two-way voice connectivity to ADT’s Health monitoring professionals and in the case of a fall, it even has the ability to send alerts if the user can’t push the button. ADT keeps seniors secure without giving up their independence. For more information, check out our Senior Living Guide for resources on how to keep cool during the hottest months of the year. FOOTNOTES 1. https://www.heart.org/en/healthy-living/ fitness/fitness-basics/staying-hydratedstaying-healthy 2. https://www.mayoclinic.org/diseasesconditions/heat-exhaustion/symptomscauses/syc-20373250

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During the 1-year follow-up period, those subscribers using the PERS had a statistically significant decrease in per-person hospital admissions and inpatient days.

On-The-Go Medical Alert for the active senior on the move

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In-home operations Home temperature monitoring Fall detection pendant* (optional) Water-resistant

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*Fall detection pendant does not detect 100% of falls. ÂŠ2020 ADT LLC dba ADT Security Services. All rights reserved. ADT, the ADT logo, 800.ADT.ASAP and the product/service names listed in this document are marks and/or registered marks. Unauthorized use is strictly prohibited. Third-party marks are the property of their respective owners. License information available at www.ADT.com or by calling 800.ADT.ASAP. CA ACO7155, 974443, PPO120288; FL EF0001121; LA F1639, F1640, F1643, F1654, F1655; MA 172C; NC Licensed by the Alarm Systems Licensing Board of the State of North Carolina, 7535P2, 7561P2, 7562P10, 7563P7, 7565P1, 7566P9, 7564P4; NY 12000305615; PA 090797; MS 15019511

Collaborative Case Management | COVID-19 Special Issue

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Collaborative Case Management | COVID-19 Special Issue