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
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; 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; 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 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;
q
Addenda
¨ Medicare average LOS by DRG
¨ CMS SNF Manual, Chapter II, Coverage of Services; Minimum Data Set for Patient Transfers; Web links
¨ ECS Acronyms and Abbreviations – Alphabetical extensive listing
¨
References
– Extensive list of references collated alphabetically by topic
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Apollo:
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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