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Prep for Success Transitions Settings
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Prep for Success: Care Transitions/Settings/Reimbursement Chapter 5: Define Gerontology the study of aging and older adults Name 2 goals (focus has shifted to…)
Chapter 6: 4M’s of Age-friendly health systems: ● Matters (know and align care w/ each older adults specific health outcome goals and care ● Medication (medication that does not interfere with what matters to the patient), ● Mentation (prevent, identify, treat, and manage dementia, depression, and delirium across settings of care) ● Mobility (ensure that older adults move safely every day in order to maintain function and do what matters) QSEN: patient-centered care, teamwork and collaboration, safety, evidenced-based practice, quality improvement, and informatics Medicare and Medicaid deny payment for certain hospital -acquired conditions that arw deemed to be preventable including catheter-associated urinary tract infections, fall- related injuries, and pressure injury stage 3 and 4 Define TRANSITIONAL CARE (lecture & p. 81) set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Effective transitional care interventions result in the following positive outcomes related to quality, safety, and cost of care: reduced all-cause readmissions, decreased mortality, and reduced hospitalizations Example: medication discrepancies during discharge are a major quality and safety concern and a factor leading to readmission w/in 30 days, particularly for older adults ex. Poor communication, incomplete information, limited access to essential services, Inadequate education of older adults and their caregivers, absence of a point person to coordinate care Why is this important? Think about the $$$ too Decrease cost- reduced all-cause readmissions, decreased mortality, and reduced hospitalizations et al., Positive Outcomes when interventions are in place:
Senior Centers: Community-based centers providing services for older adults, such as meals, limited transportation, and social and educational programs Home-Delivered Meals: Programs that provide home delivery of hot meals to homebound people, sponsored by local senior centers, churches, or hospitals Companions and Friendly Visitors: Programs that offer services such as socially oriented home visits, assistance with errands, or accompaniment to appointments Telephone Reassurance: Service providers make scheduled telephone calls to older people to provide support and reminders Internet-Based Programs: Services for support, reminders, and socialization provided via social media apps and overseen by public or nonprofit organizations. Personal Emergency Response Systems: An emergency response system that involves the use of a “call button” (e.g., necklace or bracelet) to initiate a phone call to designated people when assistance is needed (e.g., if the person falls).. Energy Assistance Programs: State and local programs that offer financial assistance for utility bills for people with low incomes Home Weatherization and Home Repair Service: Contractors paid by government agencies to provide home repairs and maintenance (e.g., insulation, window caulking, and installation) for people with low incomes Describe the 2 focuses of a PARISH NURSE (faith community nursing) : (p. 91)
Define PERSON-DIRECTED CARE (p.95 & lecture) Person-centered care (also called person-directed care or resident-centered care), defined as care that emphasizes personal choices and quality of life, is a core component of the culture change movement. Person-centered care focuses on promoting a sense of dignity and honoring individual preferences ● Culture change- describes a major movement toward implementing fundamental reform sin the ay that nursing home provide care. A major goal of culture change is to transform the philosophy and practice in nursing homes from an overemphasis on safety, uniformity, and medical care to a consumer -directed focus on health promotion, quality of life, and individualized care. Key components include:
MEDICAID also known as Title 19 is combined Federal and State funding (tax$). The Wisconsin card has the word Medical Assistance Program on it. A person is allowed liquid assets of no > $2,000 (p.99). Does this amount include the person’s home? The home is generally exempt Can an older person give all their money to their kids and then go on Medicaid? No Medicaid still treats it as a gift even up to $18,000 and will be scrutinized; strict policies to prevent the transfer of assets from one family member to another for 5 years before applying for Medicaid, however the income and assets of a spouse are usually exempt from these restrictions Initially, Medicaid paid for mainly inpatient nursing home care, but since the early 1990’s, the focus shifted toward paying for community-based services for people who otherwise would need nursing home care. (but the cost of home-care must be lower than the cost of care in an institutional setting) LONG TERM COMMUNITY-BASED CARE. 2 examples in Wisconsin ( lecture & web links in Supplemental Resources) :
● Home delivered meals ● Home health ● Home modifications ● Housing counseling ● Mental health day treatment services (in all settings) ● Mental health services (except those provided by a physician or on an inpatient basis) ● Nursing home, including Intermediate Care Facility for Individuals with Intellectual Disabilities and Institution for Mental Disease (coverage is for people under age 21, or 65 and older) ● Nursing services (including respiratory care, intermittent, and private duty nursing) ● Occupational therapy (in all settings except for inpatient hospital) ● Personal care ● Personal emergency response system ● Physical therapy (in all settings except for inpatient hospital) ● Prevocational services ● Relocation services ● Residential services o Adult family home o Community-based residential facility o Residential care apartment complex ● Respite care ● Self-directed personal care ● Skilled nursing services, registered nurse/licensed practical nurse ● Specialized medical equipment and supplies ● Speech and language pathology services (in all settings except for inpatient hospital) ● Supported employment ● Supportive home care ● Training services for unpaid caregivers ● Vocational futures planning