Welcome to

Optimizing a SNF StayKhai Nguyen, MD, MHS, HMDC

October 24, 2015UCSD 2nd Annual Geriatric Symposium

VITAS Healthcare—Hospice Medical Director VA Home-Based Primary Care – PCP UCSD School of Medicine

Geriatrics Fellowship Hospice Clinical Instructor 3rd Medical Student Geri/Hospice Lead Clinical

Instructor No ownership in any SNF or Post-Acute Care

Facility

Disclosures

Medicine- Internal Medicine/Geriatrics Board Certifications in IM, Geriatrics, HMDC

Public Health- Health Policy Emphasis Centers for Medicare and Medicaid Services

(CMS) Office of Clinical Standards and Quality Healthy Aging Project

Family member/son of a patient in a SNF for 9 months

Speaker Background

You! Patient Prospective Patient Family/Friends DPOA/Surrogate

Decision Maker Clinicians/Providers RCFE/SNFs

Intended Audience

By the end of this talk—you will: Know what a SNF is Get a better idea of what to expect in a SNF Know what to expect from a SNF Know what to expect after staying in a SNF Have a better idea of what to plan for

Objectives

SNF = Skilled Nursing Facility

Skilled Care- Qualifying hospitalization Needing “skilled care”

PT/OT/ST/RT/IV treatment/Wound Care/new tubes Custodial Care-

Longterm help with ADLs

What is a SNF?

It takes a village…

Why do we even have SNFs?

Medicare Medicaid (Medi-Cal) Private Insurance Out-of-Pocket

Who Pays for a SNF?

What Health Insurance pays for: Doctor’s visit Nurse/allied heath care Labs/Imaging/Medicines

What Health Insurance does NOT pay for: Non-emergent transportation Caregiving Room & Board

A thing about Health Insurance…

A few constants to keep in mind… Taking your child to the Pediatrician

HI covers doctor/RN/Labs/Meds HI does NOT cover you transporting child to the

office and does NOT pay for daycare

This constant is same goes for adults HI does not cover non-emergent

transport/caregiving

Why does our HI not pay for transportation and caregiving?

So why are you at this talk?

85 y/o female with Alzheimer’s Dementia who was sent to the Emergency Room for a fall at home while trying to go to the bathroom at 3AM.

Dx: Osteoporosis Left Hip Fracture1-Year Mortality is

20-50%also a Urinary Tract

Infection

So you know someone in a SNF?

After 3 days in the hospital and orthopedic surgery

Cannot go home yet because cannot transfer independently

Recommended to go to a Skilled Nursing Facility

So you know someone in a SNF?

“Where do we go from here?”

Home Independent Living Assisted Living Memory care/assisted living Board & Care/Group Home Nursing Home (Skilled or Custodial) Sub-Acute Care Hospitals

Continuum of Care

Prior and current level function ADLs = Activities of Daily Living

1) Eating2) Bathing3) Dressing4) Toileting5) Transferring/Walking6) Continence

The Key is ADLs

Hospital Street, USA

RCFE-Independent Living

Board & Care Land

ER-Land

Hospice Land

Home

SNF-Skilled/Custodial

EntranceExit

Planning for Life’s Health Outcomes

Advance Directives

POLST

Talk with family/surrogate decision makers

GOALS OF CARE

Ideal

Reality

Good: Rehab* Bad: Heavily regulated and punished** Ugly: Bad things can happen…***

* Depends on many factors, mainly prior level of functioning/will** Breeds a culture of fear, focus on rules not people, apathy***But can be prevented

The Good, The Bad, and The Uglyof SNF…

Caring for our elderly family/patients Who’s the Village?

Doctors Nurses (NP/RN/LVN) Therapists (PT/OT/ST/RT) CNAs MSW/Administrators FAMILY

It takes a village…

Eating Laughing Loving The Dark Side- being alone, feeling isolated

etc…

It’s a social thing…

Advanced Directive POLST TALK TO YOUR FAMILY

Must Know: Goals of Care

Depersonalization of Healthcare Photos/Collage Frequent Family Visits Timely Family Visits (mealtimes and wakeup) Organize Family visits to optimize time

capital Get in the trenches Don’t be passive

Humanize the Patient!

Listen to your doctors as long as they are listening to you

Challenges: Doctors

Helping families and patients: help themselves navigate the defragmented health “non-

system” finding funding sources mental health and wellbeing everything non-medical needs

Challenges: SNF MSW

Past & Recent controversies (professionalism)

Disparity in training (Physicians vs CNA) Lack of cultural and aging health training Lack of good pay/benefits Lack of support Plethora of patients (high patient to staff

ratio)

Challenges: SNF Staff

Medical Psychosocial Financial Loss/Grief Dependence

Challenges: Patient

Change of dynamic from healthy family member and sick family member

Allowing others to help take care of your loved one

Ill-defined responsibilities

Challenges: Families

Paradigm shift SNF corporations Public Health State/County regulators Joint Comission Transparency of costs

Challenges: Society/Community

“What does love got to do with it?”

Society/social policies wants us to take care of our own!

Families step up policies And YES, be nice to your kids, they may very

well be choosing the “cheapest” SNF for you!

Love has everything to do with it!

Fear not—just plan It’s not the end of the world…yet Goals of Care Denial is a strength – Denial is a weakness

Take Away Points

SNF Stay Optimized!

THANK YOU

Questions & Discussion