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Acute Care > Discharge Planning > Flashcards

Discharge Planning Flashcards

1
Q

Acute Care Discharge Algorithm

A
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2
Q

Discharge with an emphasis on Rehabilitation

A
  • Inpatient Rehabilitation
  • Skilled Nursing Facility
  • Swing Bed
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3
Q

Inpatient Rehabilitation

A
  • Goal to return patients to home safely and as independently as possible
  • High intensity program with goals to maximize functional gain in a shorter time frame
  • Team approach
  • Patient and family / caregivers involved in plan of care
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4
Q

Inpatient Rehabilitation vs Skilled Nursing Facility

A

Inpatient Rehabilitation
* Medical Director / physicians specializing in Rehab
* Daily rounding
* 24-hour specialized nursing care
* Team approach
* Functional outcomes benchmarked nationally
* High rate of discharge to home
* Shorter length of stay
* Intense rehabilitation must include at least 2 disciplines:
– 3 hours / day x 5 days / week
– 15 hours / week over 7 days (modified schedule)

SNF
* Any physician can cover
* 1 MD visit / 30 days during first 90 days, then only as needed
* An hour to two hours a day based on pt tolerance
* May be difficult to carry over therapy plan of care due to structure of staffing
* Length of stay may be significantly longer (Can’t tolerate that rigor of therapy so they come here)
* Therapists are generally seeing patients 5-6 days / week, but even at the highest threshold for therapy, the patients are not receiving more than 14 hours of therapy / week

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5
Q

What assessment tool is used in inpatient rehab and SNF?

A

CARE (Continuity Assessment Record and Evaluation) Item Set

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6
Q

In order for SNF to be covered

A

requires that stay is related to acute hospital stay, that the patient had a three-night qualifying stay in an acute care setting within the last 30 days, and that the patient needs daily skilled services (RN, PT, OT)

Short Term Stay

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7
Q

Swing Bed vs SNF

A

Very similar, Swing bed is rural. Benefit is that they can be closer to home in swing bed.

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8
Q

Discharge with Emphasis on Long-Term Care

A
  • Skilled Nursing Facility
  • Palliative Care
  • Hospice Care

Palliative and Hospital requires a medical physician and holistic medical providers referral

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9
Q

Skilled Nursing Facility has ____ monitoring and medical assistance

A

24 hour

Home for residents.

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10
Q

Long Term Stay SNF Cost Factors

A

Size of room
Whether a room is private or semi-private
Geographical location of the community

Semi-private: $247 per day
Private: $280 per day

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11
Q

Palliative Care

A
  • Years out from death; Focus on comfort and quality fo life
  • Palliative careis patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering.
  • Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information and choice. Holistically treating the patient.
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12
Q

Hospice Care

A
  • Hospice focuses on caring, not curing and in most cases, care is provided in the patient’s home.
  • Two physicians determine Pt has prognosis of 6 months or less to live
  • Provide comfort through exericse or ROM, teaching family bed positioning, equipment recommendations
  • Per Diem: One fee daily, does not change with more or less equipment or medical professionals
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13
Q

Discharge with Emphasis on Return to Home

A

Home (independent house / apartment / condominium / mobile home / caregiver’s home)
* Outpatient therapy
* Home care therapy
* Supportive Home Care
* Respite Care

Supportive Home Settings
* Independent Senior Living Communities
* Assisted Living Facilities
* Memory Care
* Residential care homes (group homes)

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14
Q

Outpatient PT

A
  • Intermittent therapy services provided in a clinic, hospital, or nursing home setting to which the patient travels
  • About 10 visits for medicare coverage
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15
Q

Skilled Home Care

A
  • Pt must meet homebound criteria to be eligible for skilled home care
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16
Q

Skilled Home Care

A
  • Pt must meet homebound criteria to be eligible for skilled home care
  • Requires a considerable and taxing effort for the patient to leave the home, obtain similar services, and return to the home
  • May include RN, PT, OT, speech therapy, and CNA services
17
Q

Supportive Home Care

A
  • Supportive home care allows older people and those with disabilities to remain in their own homes while receiving the assistance they need to help them remain independent.
  • ADLs, IADLs
  • Ex: Community Clients
18
Q

Respite Care

A
  • The term “respite care” typically refers to a short-term stay at a senior community residence, though it may be used in reference to in-home caregiving services used for only a short period.

This type of care is often used when:
* The family caregiver needs to travel
* The family caregiver needs a break
* As a trial of a senior community, when a family is deciding whether a community is right for them
* A caregiving recipient needs a temporary change of pace, or a break
* A family is gradually easing their loved one into life at a senior community residence

19
Q

Independent Senior Living Communities

A

Independent senior living communities cater to seniors who are self-sufficient and who do not need hands-on care.

20
Q

Assisted Living Facility

A
  • Assisted living communities provide housing and care to seniors who may need some assistance with daily tasks, but who do not require the skilled care provided at a nursing home.
  • Assistance with medications, activities of daily living, meals, and housekeeping are routinely provided.
  • 24 hours a day; keep people busy
21
Q

Memory Care

A
  • Alzheimer’s and dementia care, also known as memory care, is often provided in a secure area of an assisted living community or nursing home, usually on a separate floor or in its own wing.
  • ADL
  • Staff have additional training
22
Q

Residential Care Home (Group Homes)

A
  • Residential care homes offer many of the same services as larger assisted living facilities, but they do so in smaller, more home-like settings.
  • Most residential care homes employ, or are run by, nurses and are home to 10 or fewer seniors and/or those with disabilities.Smaller home setting.
  • Live-in caregivers provide 24-hour supervision and assistance for residents.
23
Q

Adult Day Services

A
  • Allow for caregviver to go and do whatever they need to.
  • Half or Full Day
  • Provide care for those with physical disabilites and/or cognitive impairments
  • Ex: APTIV

Acute Care (26 decks)

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