AGING AND DISABILITY NETWORK OF SARATOGA COUNTY MEETING
Minutes April 9, 2013 held at The United Methodist Church, Saratoga Springs, NY
Present: Cindy Harrington (Shelters of Saratoga), Maria Geizer (Home Instead Senior Care); Linda Powers (Home Instead Senior Care); Ann Quinn (Home Health Care Partners); Kara Clark (Home Health Care Partners); Jess Froehlich (Eddy Day Break); Erica Salamida (Alzheimer’s Association); Cathy Tucker (Ameriprise Financial); Patrick Harrington, Ben Nichols, Mary Rickard, Connie Weaver, Ardis Armer, Mary Sala, Jean Tulin (Saratoga County Office for the Aging – NY Connects); Rebecca Zahn (Concepts of Independent Choices, Inc. ); Noreen Jones (O’Neil Apartments Senior Coordinator); Kym Hance (Home Helpers); Darlene Landor (Today’s Options); Donna Rudzinski (Shenendehowa Village) Doug Kesler, Kathy Wallace (Southern Adirondack Independent Living); Krissy Goodspeed (Interim Health Care); JoAnn Zales (National Grid); Mary Buszuwski (The Senior Living Specialists); Reed Lehan (Saratoga County DSS)
Introductions: Cindy Harrington welcomed attendees and announced that the next meeting will be on May 14th at St Edward’s the Confessor Church, 569 Clifton Park Center Road, Clifton Park. Attendees introduced themselves.
Announcements:
1. Home Instead is sponsoring “Managing Family Care for Alzheimer’s Patients” on April 10th & April 17th at 1:00 PM. The program is free and Continuing Education Unit (CEU) eligible.
2. Shelters of Saratoga (SOS) and the Warren-Saratoga-Hamilton-Washington-Essex (WSHWE) BOCES culinary arts students have been selected to participate in a State Farm Neighborhood Assist contest to win $25,000.00. The project called “Culinary Kids Caring” needs you to vote for them on the State Farm Neighborhood Assist Facebook page 10 TIMES every day from APRIL 4 through APRIL 22. Log into your Facebook account enter the following link: https://apps.facebook.com/sf_neighbor_assist/ and click “Vote Now”, click on NY state on the map, click on the “bullet” for “Culinary Kids Caring” and progressively vote until “0 votes remain”!!!
Presentation: Topic: Discharge Planning 101 & Saratoga Hospital Care Management - The Role of Nurse Care Managers and Social Workers in Preparing for a Safe Patient Discharge Across the Care Continuum.
Speakers: Diane Gaylord RN, Operational Coordinator, Care Management, Saratoga Hospital and Jennifer Baldwin LMSW, Care Management, Saratoga Hospital
An overview was presented about the roles and responsibilities of the Care Management Team along with the challenges, successes, and what community resources, referrals and supports are available to achieve a safe discharge plan for patients after hospitalization.
Who is the “Care Management Team?”
The Care Management Team is a team of nurses and social workers that work closely with the interdisciplinary team of physicians, nurses, physical/occupational therapists, nutritionists, clergy, and other specialist to plan, manage and coordinate patient centered care needs across the continuum.
The role of Care Management is integrated and starts at the point of entry in the Emergency Department. Here, the Patient Care Coordination works with the Care Management Team to assess the patient’s baseline functioning and needs, and identifies the patient’s support systems and key individuals that will support a care plan and be involved in decision making. (Note: Patients must give permission for family/care giver involvement).
Discharge Planning Process (Points presented)
· The transition (discharge) planning process starts on day #1 of hospitalization
· Patient and family are active participants in the discharge planning and making choices throughout patient care and treatment
· Interdisciplinary team members review the plan of care daily in rounds to make needed changes based on progress and changing conditions
· Coordinating available services and programs with communication on a regular basis is key to successful planning
· The goal is to help the patient achieve the highest level of functioning, strength, and skills needed to return home
Care Management Assessment for Home
· What is the patient’s baseline and illness impact on functional ability?
· Mobility recommendations – can the patient ambulate safe house hold distances?
· Assistive devices – walker, cane, commode, wheelchair or others needed
· Assessment for Visiting Nurse, Home Health Aide, PT/OT, Nutrition, Social Worker, Office for the Aging – Community Care Transitions, Outpatient Rehabilitation service needs, transportation, lab draws etc..
· Life-Line for emergency situations
· Supplement additional resources: 24-hour care/supervision –private hire, companion services and others
· Medications for discharge – comprehension, reconciliation, prescription filling and financial coverage
· Verification of the following PCP & physician appointment
Criteria for Home Visiting Nurse
· Must meet a skilled need –ex. Medication compliance, cardiovascular assessment, wound care, IV medication administration, injectable medications, therapies etc.
· Additional needs may include: Rehabilitation services- physical therapy, occupational therapy, speech therapy, nutritional therapy, medical social worker, Home Health Aide, Fall Safety Assessment
· Patient must be home-bound for some insurance requirements
· Referral ordered by the physician (Medicare requires the “face-to-face” requirement)
· Patient/Family Education – NEW “teach back” techniques (Example – CHF Toolkit teach back)
· Long Term Medicaid Care programs, Consumer Directed
· Payment options: Medicare, Medicaid, Private Insurance & obtaining their approval
· Availability – depends on skilled need (2-3 times per week for 1-2 hours
Important Discharge Tips for Patients
· Choose a Primary Care Physician and keep annual healthcare check ups
· Know your medications and keep a current list of your medications with you at all times
· Discuss with your Pharmacist any concerns you may have regarding medications, side effects and contraindications
· Know your own risk factors for disease and take steps to reduce (high Cholesterol, high blood pressure, diabetes, stressful lifestyle, lack of exercise, smoking and others)
· Stay current with Flu and Immunizations
· Identify an individual that you trust to be your advocate with healthcare needs (HCP)
· Take steps to enrich your life in spirit and engage in fulfilling relationships
Inpatient Short-Term Rehabilitation
Some adults will require Short-Term Rehabilitation following hospitalization due to illness, post-surgical conditions, orthopedic recovery, stroke and neurological recovery. Again, the goal is to help the patient achieve the highest level of functioning, strength and skills needed to return home. Care Management works with patient for choice of facilities.
Criteria for Transfer to an Inpatient Rehabilitation Facility
· Based on patient progress and functional ability regarding personal care and mobility
· Factors considered: Prognosis for improvement, desire and motivation to improve. Are these achievable goals?
· Patient safety, home environment and support systems for health and rehabilitation goals
· Financial approval based on Medicare or private insurance criteria guidelines
· Skilled Facility Rehabilitation: 1-2 hours per day of therapy for 1-3 weeks (may include physical therapy, occupational, speech and other therapies)
· Acute Rehabilitation – patient needs can tolerate 3 hours per day of various skilled therapies (two or more disciplines)
Long Term Care
The patient may need Long Term Care options or a LTC facility due to inability to take care of themselves, long term medical needs, lack of support systems, financial resources (care at home is not an affordable option) and 24 hour care and/or supervision needs. Considerations: Referrals to Nursing Home Transition Diversion Waiver Program, Consumer Directed, LTC program or Nursing Facility Long Term Care.
The Long Term Care Facility Placement Process
· Social Worker helps lead the patient through the process to answer all questions and help complete the Long Term Care facility application
· Assistance with support and referral for those patients that require Medicaid applications for nursing facility long term planning
· Other LTC Resources – County Department of Social Services, Office for the Aging
· Choosing 8 facilities for LTC placement initially & expand search to other facilities weekly
· Selection of first available bed from the facilities chosen -per Medicare or insurance provider guidelines
· Lateral transfer arrangements are always available
Challenges in Navigating Healthcare Options from the Hospital
· Our encounter with the patient is during an episode of illness, surgery, health emergency or crisis
· Assessing the overall needs within a short period of time (average length of stay 4-5 days depending on diagnosis)
· Obtaining insurance coverage for all services needed –daily communication is required
· Lack of affordable services between the home setting and long term care
· Ever-changing long term care process (ex. 5 year look back on finances)
· 30 day all cause readmission concerns
Successes
· New technology advances to identify at risk patients at point of entry (text phones, SMART Boards, real time data)
· Collaborative and collegial community partnerships for patient referral, same day assessment, service set up to bridge the continuum, quarterly meetings for comprehensive care planning and safety net in the community. Working with all of you!
· Nursing call backs (goal 100%) & re-engineering the discharge process
· NEW – Community Care Transitions Program through the Affordable Care Act – Saratoga Hospital and Saratoga County Office for the Aging
· Provider to provider “hand-off” communications
· Web access to community resources
Respectfully Submitted,
Jean Tulin
Saratoga County Office for the Aging - HEAP
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