Goodbye post acute care Flashcards
article stat
more than 10,000 people a day reach medicare age
post acute care
In response, many healthcare providers are re-engineering their pathways of care to promote alternatives to repeated hospitalizations. These alternatives—filling in what some have called the fragmented “chasm of care” in post-acute settings—include greater use of palliative-care specialists, geriatric nurse practitioners, expanded roles for pharmacists and social workers and patient navigators in patient- and family-centered home-based and community programs.
community based care (away from hospital setting)
In the future, a greater portion of the heavy-lifting of healthcare will be performed in many non-hospital settings, post-acute settings and beyond. Because of that shift, we call it community-based care.
community care is the future metric to judge a provider
That is, their reimbursement will be based on performance of care rendered in multiple provider sites by various types of caregivers, including in-home settings.
telemedicine and new biogenetic devices
increased electronic connectivity causes:
- reduce over time much of today’s unnecessary procedures and acute-care stays
- error-prone medication ordering practices
- patient noncompliance.
Community-based care programs are demonstrating that participation is best achieved in :
the residential setting
In the home, patients and family members are more relaxed and able to remember what they are taught.
Home/ residential setting
While there are exceptions, the home is the preferred setting to discuss
1.disease management
2. prevention counseling,
3.lifestyle changes
4. end-of-life care.
Sending providers to the home also enables a social assessment of the environment and evaluation for referral of other services such as custodial support
two services in Southern California
Two relatively new services in Southern California are showing positive results using a community-based approach
- the Outreach Care Network in Pasadena. OCN started as an outpatient palliative-care service but has evolved to serve patients with multiple chronic or life-limiting illnesses, most of whom have had multiple trips to the emergency department or numerous hospitalizations.
- OCN reduced avoidable admission and ED visits
- Care RX
The second program, offered by hospice pharmacy advisory company CareRx, sends a pharmacist into the home setting for face-to-face meetings with patients and family members. A typical patient has multiple chronic and progressive diseases, nine-plus medications, two or more prescribing physicians, medication adherence problems and is likely to be noncompliant with the medication regimen.
TRUE OR FALSE. up to 35% of hospital readmissions are caused by some type of medication-related problem
TRUE
Home care visits
situations, home-visiting pharmacists improve care transitions by conducting medication reconciliations at home rather than in the hospital. Unlike nurses and other types of clinicians, pharmacists are viewed as experts on medications, and patients tend to openly communicate with them, especially in the home setting. Also, they can actually see patients’ medications and dosage information, which patients often fail to recall or mention while in the hospital.
home visiting pharmacists are part of
care team with case managers, primary care physicians, and caregivers
Care Rx
The 30-day readmission rate is less than 2%, and the
90-day readmission rate is 23% versus more than 34% nationally for all Medicare patients.
Post acute care
Post-acute care includes rehabilitation or palliative services that beneficiaries receive after or in some cases instead of, a stay in an acute care hospital. Depending on the intensity of care the patient requires, treatment may include a stay in a facility, ongoing outpatient therapy, or care provided at home.
