Managing Post-acute Care and Other Extended Care Services

Policies, procedures and tools to 1) improve efficiency and quality, while controlling the cost of care for any skilled facility, rehabilitation service, home care or related long-term care service and, 2) provide methods and criteria to objectively and appropriately transition patients across the continuum of care from acute inpatient to subacute or inpatient rehabilitation, skilled outpatient care and, when applicable, custodial care services. 

List of Contents  

q     Introduction – Introduction, UM for extended care services, Medical necessity defined;

q    Post-acute and Extended Care Requirements - Selecting the most appropriate setting, Evaluation definitions, Chronic pain assessment, Outcome management, factors for success, Provider requirements for Medicare HMO contracts, Functional Independence Measures (FIM), Identification/monitoring: Cost factors, Improve operational efficiencies and communication, Length of stay benchmarks, ECS Facility Network, UM Case Management for Skilled Nursing Facility Services, Concerns about SNF admissions?, Centralized extended care service resource and care management, ECS Resource Center Staff Forums and Grand Rounds, Strategic Initiative to Improve Triage Decisions, Telephone Encounter Guidelines and form, Preadmission Screening by the ECF, Preadmission Screening Tool, OASIS, Hospice care in the nursing facility

q    Case or Care Management - Case Management process; Case Management Program; Case Management Referral Indicators; Target Diagnoses for CM Services; COPD, Parkinson's Disease, Heart Failure, Diabetes, Heparin-Coumadin conversion; HIV, Hip fracture; Mental Health CM: Policy, Depression, Obstetrical CM; CM loads; Case Management Screens; Case Management – new patient screens/triggers; High risk screen examples; Catastrophic conditions report; Planning the continuum of care; Hospitalist program post-discharge transitional management of care; Director of Case Management Services, position description; Case Manager, position description; Discharge Planner, position description; Case Management Department staff responsibilities; Case Management Credentialing Resources; CM Resources, References.

q     Levels of Care - SNF Guidelines: Level of Care assignment, SNF Levels of Care for payment, Skilled Services and procedures coverage; Glucose monitoring coverage in a SNF; Centralized extended care service resource and care management; Skilled Services; Strategic Initiative to Improve Triage Decisions; SNF Case Management; Scope of services by level (chart), Transitional Care Unit Guidelines; Hospice; Educational brochure/handout

q     Defining Skilled Services - Skilled vs. unskilled nursing services, Physical Therapy Defined, Skilled vs. unskilled physical therapy services, Skilled vs. unskilled occupational therapy services, Skilled vs. unskilled speech therapy services, Speech and Voice Therapy; Authorization guidelines, Skilled vs. non-skilled services criteria, examples; Custodial care

q    Managing Extended Care Services - Service Standards and Procedures, Hospital Admission Review; LOS, Level of Care, Direct Admissions, Admission process for Extended Care Facility Patients, Voluntary Placement of Custodial Patients; admission from home, ECS ‘Against Medical Advice’ policy/procedure, Transfer from ECF to Acute Level of Care, ECS Clinicians ;best practices’ for continuing care, Transitional Continuity of Care Plan, Discharge Planning, ECF Discharge to home or residential care facility, Transfer from Acute Care to ECF, Podiatry services, Chiropractic services, Speech Therapy

q     Acute Inpatient Rehabilitation – Introduction, Criteria for admission, Preadmission review for rehabilitation, Rehab criteria, Continued stay review, Discharge status review, Case Mix, Severity Indices and Complexity of Care, Stroke/CVA, Spinal Cord Injury with paraparesis/paraplegia; dorsal/lumbar, Spinal Cord Injury w. paraparesis/paraplegia; cervical, Amputation, lower extremity, Traumatic Brain Injury Fracture of Femur/Hip/Arthroplasty, Pediatric Rehabilitation; Levels of care, Rehabilitation Benchmarks, Rehabilitation Benefits, Cardiac Rehabilitation, guidelines with references

q     Stroke Rehabilitation Guideline - Introduction; Key components of a rehabilitation program; Stroke prevention – primary and secondary; Initial assessment and stabilization; Criteria for inpatient rehabilitation; Goals for rehabilitation services; Post-stroke rehabilitation check list; Depression; Initiation of rehabilitation services; Rehabilitation referral criteria – decision tree; Speech therapy; Coverage issues; Rehabilitation unit discharge criteria; robotic-assisted rehabilitation of the upper limb after stroke; Stroke rehabilitation algorithm; Standard instruments for patient assessment following a stroke; Constraint induced movement therapy; Electrical stimulation therapy; Home care vs. day hospital post-stroke;  Stroke Centers; Notes

q   Forms - ‘Patient Care Plan’ Authorization Form, Request for authorization for additional services, Physical Therapy Progress Note/Request for continuation, Referral Authorization, general format, UM form for Home Health, Oxygen and DME, Physical Therapy order forms

 q   Durable Medical Equipment: Coverage Guidelines – Definition, Communication devices, Elastic garments; Orthotic/prosthetic devices, Prosthesis criteria: functional levels; Prosthetics & orthotics ordered in a hospital or home prior to a skilled nursing facility admission - payment issues;

Neuromuscular electrical stimulators, Therapeutic electrical stimulation, Transcutaneous electrical nerve stimulation (TENS), Percutaneous electrical nerve stimulation (PENS), Shoe inserts to relieve back pain in patients with leg length discrepancies; Therapeutic Shoes, extensive DME list of covered and non-covered equipment

 q     Potpourri - Assessment and Prevention of Falls; Common management issues, Claims review for extended care services, Resistance training for older individuals, Preventive physical activity regimens, Post-Work Injury Evaluation and Hardening, Handicapped Access Guidelines, SNF/Home Health Educational Brochure, example; Legal issues - elder abuse

q     Quality Assurance and Improvement - Quality Improvement guidelines/outcome studies; Hospital/SNF QA Screens, Rehab Care; QI Indicators, Quality ‘flags’; Measuring satisfaction: post-acute facility care; Medical Record Review; ECS Site Survey Review Tool; Provider alerts to QA Committee representatives; Urgent Complaint Resolution Policy

q     Home Health Care/Hospice - Introduction, Home Care and Hospice Case Management - policies and procedures; Maternity and Newborn Care Services;  JCAHO Emergency Preparedness for Home Care; Home Health/Hospice - Case Management; Homebound criteria; Home Health Visits to a Blind Diabetic; Home health nursing visits to patients requiring heparin injections; Common reasons for failure of Home Health Case Management; ‘Homebound’ physician-based program; Skilled Home Nursing Care, private duty; Home Nursing for Ventilator or C-PAP Patients; Homecare physician visits; Home Care Plan Oversight; 

Home Health Teaching Coverage (Catheter Care and Feeding Tube Care Coverage, Complex medication regimen supervision, Pressure ulcers – prevention and care, Wound care); Home Health Referrals; Termination of Home Health Care Services; Home Health Aides/Assistants; Caregivers; Home Health Infusion Services; Home Ventilator Management; Oxygen Coverage Guidelines; Home Social Work Services; JCAHO 2004 National Patient Safety Goals; Home Safety Visit Check List; Hospice eligibility and coverage requirements; Hospice Care in the SNF; Karnofaky Performance Scale; Patient Choice/Disclosure for selection of HHA; Personal assistance services for ADL; Care Plan Oversight – Medicare regulations for home health, hospice coverage; Dementia criteria for hospice; North Dakota Health Care Review: Home Health Quality Initiative - links; Resources – Home Health Care Services; Web links for Home Health Care, Hospice;

 q     Education - Educational materials, introduction; Patient Education Materials - Development, Approval and Review P & P; ‘Self Care’ or ‘Self-management Educational Programs; Diabetes Outpatient self-management training programs; References/resources – healthcare education programs; Institutional and Home Care Patient Education Programs, Medicare NCD; Diabetes Self-management Training, Medicare coverage; Education as a utilization strategy; Education notes.

 q     Addenda

E-mail Apollo: apollomanagedcare@cox.net to request example pages from any listed content.

Managing Post-acute care and Other Extended Care Services is a 480 page loose-leaf manual accompanied by the entire contents on CD. 

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