老年病人的出院计划（英文ppt）dischargeplanningforthegeriatricpatientpearlsandpitfalls课件

Discharge Planning for the Geriatric Patient: Pearls and Pitfalls,Adrienne Green, M.D. Bill Lyons, M.D. University of California San Francisco,Developed with support from the UCSF Academic Geriatric Resource Center,Objectives,Understand predictors of poor discharge outcomes in the elderly patient Appreciate alternatives for post-acute care Home Care Skilled nursing or sub-acute facilities Acute rehabilitation facility Hospice Provide strategies for improving discharge planning, communication and outcomes,Background,10 million discharges/yr Medicare pts Quicker and sicker discharges of older and frailer patients JCAHO guidelines for multi-disciplinary d/c planning as component of high-quality care HCFA regulates discharge planning Poor hospital reimbursement if pt no longer acute,Predictors of Poor Post-Discharge Outcomes,Age 80 Multiple, active medical problems Multiple hospitalizations last 6 months Hospitalized within last 30 days History of depression,Moderate-to-severe functional impairment Inadequate support system “Fair” or “Poor” self-rating of health History of non-compliance,Case #1: Home Care,Ms. Bea Atome is an 82 y/o woman with colon CA s/p resection with new colostomy. Hospitalization complicated by delirium and line infection requiring 2 weeks IV antibiotics. Pt. lives alone, scant family in Wisconsin, never finished grade school, neighbors help with grocery shopping.,Case #1: Home Care,Pt. is AAO X 3. Can do basic ADLs but ambulation limited by osteoarthritis and deconditioning. You decide that Ms. Bea Atome is able to return home with home health.,What are predictors of home health use?,Lower educational level Less accessible social support Impairment in at least one IADL Prior home health care use Solomon et al. J. Am. Geriatric Soc. 1993,What are this patients post-discharge needs?,IV antibiotics Ostomy care and education PT/OT Assistance with bathing, cooking, shopping etc.,Is this patient “homebound?”,Medicare/Medical only reimburse if pt “homebound” with skilled needs “Homebound”: “Great and taxing effort” to get out of the house Still permitted: rare clinic visits; religious services; hair appointments,What in home services are covered by Medicare?,Short-term skilled care RN PT, OT, SLT Medical SW Home health aide ( limited personal care/assistance with ADLs) Attendant care (cooking,cleaning etc.) not covered In general, reimbursement very insurance dependent,Home Care Nursing,Diabetes management Ostomy care IV management Medications Self-catheterization Self-injections Tube feedings,Wound care (no more than b.i.d) Excellent teaching for all of the above,Home Care Order Writing,General Tips “RN to assess self-care ability” “RN to assess medication compliance” “RN to provide teaching to patient/family” “RN to assess pain control” “OT to assess home safety” Clarify M.D. to follow up home care orders Sign your orders (significantly effects home care reimbursement)!,Intravenous Therapy at Home,Requires teachable, cooperative pt and family (esp. if dosing more than qD) Frequent administration (e.g., q4h antibiotic) may be possible with cassettes First dose antibiotic must be given in the hospital PCA possible, no transfusions,Case #2: SNF vs.Rehab,Mr. Sniff is an 84 y/o man admitted with pneumonia and COPD exacerbation. Prior to admission he had been living independently. Due to prolonged intubation, he becomes profoundly deconditioned but is motivated to regain his pre-morbid ability to walk. You discuss post-acute care options with the patient and his family.,Case #2: SNF vs. Rehab,The pts daughter demands that her father to go to rehab. How do you explain to her the difference between SNF and rehab?,Acute Rehab: Admission Criteria,Pt. can do 3 hours per day of therapy Needs close medical supervision Needs multidisciplinary, coordinated program of care Clear and realistic goals Has a clear post-rehab discharge plan,SNF: What makes a good candidate?,Needs skilled nursing IV antibiotics, respiratory care, tube feeds, TPN, complex wound care Needs rehab services PT/OT/SLT Pre-morbid functional status (including cognition and mobility) predicts prolonged institutional stay,Admission Criteria for Sub-acute,Trach or ventilator, or Any 3 of following 6 criteria TPN PT/OT/SLT Tube feeds Inhalation therapy Continuous or frequent IV therapy Complex wound care,Case #2: SNF vs. Rehab More tough questions,Mr. Sniffs daughter states that she has heard horrible things about SNFs. She wants to know exactly what to expect for her father. Would he be okay if his breathing got worse again?,SNF: What can the patient expect?,“The term nursing home is somewhat of a misnomer: relatively little nursing care is provided ( average of 70 min/day of nurses aide care), and most facilities do not have a homelike atmosphere.” Kane, Ouslander and Abrass. Essentials of Clinical Geriatrics.,SNF: What can the patient expect from his/her physician?,Rarely on site See pts on admit, mostly phone management thereafter Minimal diagnostics available No on-site x-ray, ecg, labs Manage consequences rather than causes of illness,SNF: What can the patient expect from SNF staff?,LVN/CNA RN May be one LVN per 30 pt; one RN per 50 pt High turnover Low level of sophistication Usually good rehab services Interdisciplinary approach to care,Determinants of SNF Reimbursement,Must have 3 day hospital stay to qualify for Medicare SNF benefit Extent of rehabilitation needs and number of disciplines Nursing and technological complexity (tube feeding, IVs, wound care) Medicare pays only for first 100 days of skilled care SNF bankruptcy not rare,Case #2: ready for discharge?,You convince the patient and his family to go to the local SNF with a possible transfer to rehab once he has regained some strength. You are about to approach the 12L social worker for assistance with the transfer but know there are some things you had better do first. What do you put on your “scut list” for the day?,SNF: Discharge Planning,Dictated discharge summary must accompany pt. to SNF Call to PMD; call to SNF MD if pt. medically or psychosocially complex Address and document code status Document PPD or CXR results Document need for psychoactive medications ( highly regulated at SNF),Case #3: Hospice Care,Ms. Comfort is a 75 y/o woman with metastatic breast CA. She is admitted to the hospital for SOB due to lung mets and malignant pleural effusions. There are no further chemotherapeutic options and efforts to provide symptomatic relief with thoracentesis and pleurodesis have failed.,Case #3: Hospice Care,The patient lives at home with her husband and has 2 devoted children nearby. She understands her prognosis and would like to be at home to spend as much time as possible with her family. You believe she is a good candidate for hospice care.,Hospice Philosophy,Support and care in last phase of incurable disease so that pt can live as fully and comfortably as possible Affirms life and neither hastens nor postpones death Create environment to provide pt. and family satisfactory mental and spiritual preparation for death. National Hospice Organization Mission Statement,Where can hospice care be provided?,Home Requires pt. to have help at home Not required to be homebound SNF Residential Hospice Facility Medicare hospice benefit does not cover room and board,Medicare Hospice Benefit,Life expectancy 6 months Guidelines exist for determining prognosis in pts with non-cancer illness Pt. gives up standard Medicare benefits Certified hospice program,Services covered by the Medicare Hospice Benefit,24/7 On-call services Physician services Nursing services Social Services Equipment required for palliation of illness Meds for symptom management and pain relief,Short term hospitalization/respite care Home health aide PT/OT/SLT,Discharge Planning Pearls and Pitfalls,Pitfalls Poor communication,Pearls Call PMD on admit and discharge Call SW early Dont surprise the patient and family Realist