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Welcome to
Optimizing a SNF Stay
Khai Nguyen, MD, MHS, HMDC
October 24, 2015
UCSD 2nd Annual Geriatric Symposium
 VITAS Healthcare—Hospice Medical Director
 VA Home-Based Primary Care – PCP
 UCSD School of Medicine
 Geriatrics Fell...
 Medicine- Internal Medicine/Geriatrics
 Board Certifications in IM, Geriatrics, HMDC
 Public Health- Health Policy Emp...
 You!
 Patient
 Prospective Patient
 Family/Friends
 DPOA/Surrogate Decision
Maker
 Clinicians/Providers
 RCFE/SNFs...
 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 exp...
 SNF = Skilled Nursing Facility
 Skilled Care-
 Qualifying hospitalization
 Needing “skilled care”
 PT/OT/ST/RT/IV tr...
 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 Insura...
 A few constants to keep in mind…
 Taking your child to the Pediatrician
 HI covers doctor/RN/Labs/Meds
 HI does NOT c...
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 ...
 After 3 days in the hospital and orthopedic surgery
 Cannot go home yet because cannot transfer
independently
 Recomme...
“Where do we go from here?”
 Home
 Independent Living
 Assisted Living
 Memory care/assisted living
 Board & Care/Group Home
 Nursing Home (Skil...
 Prior and current level function
 ADLs = Activities of Daily Living
1) Eating
2) Bathing
3) Dressing
4) Toileting
5) Tr...
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...
 Caring for our elderly family/patients
 Who’s the Village?
 Doctors
 Nurses (NP/RN/LVN)
 Therapists (PT/OT/ST/RT)
 ...
 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)
...
 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 sourc...
 Past & Recent controversies (professionalism)
 Disparity in training (Physicians vs CNA)
 Lack of cultural and aging h...
 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 on...
 Paradigm shift
 SNF corporations
 Public Health State/County regulators
 Joint Comission
 Transparency of costs
Chal...
“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, t...
 Fear not—just plan
 It’s not the end of the world…yet
 Goals of Care
 Denial is a strength – Denial is a weakness
Tak...
SNF Stay Optimized!
THANK YOU
Questions & Discussion
2015: Optimizing a SNF Stay-Nguyen
2015: Optimizing a SNF Stay-Nguyen
2015: Optimizing a SNF Stay-Nguyen
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2015: Optimizing a SNF Stay-Nguyen

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Optimizing a SNF Stay

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2015: Optimizing a SNF Stay-Nguyen

  1. 1. Welcome to Optimizing a SNF Stay Khai Nguyen, MD, MHS, HMDC October 24, 2015 UCSD 2nd Annual Geriatric Symposium
  2. 2.  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
  3. 3.  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
  4. 4.  You!  Patient  Prospective Patient  Family/Friends  DPOA/Surrogate Decision Maker  Clinicians/Providers  RCFE/SNFs Intended Audience
  5. 5.  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
  6. 6.  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?
  7. 7.  It takes a village… Why do we even have SNFs?
  8. 8.  Medicare  Medicaid (Medi-Cal)  Private Insurance  Out-of-Pocket Who Pays for a SNF?
  9. 9.  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…
  10. 10.  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?
  11. 11. So why are you at this talk?
  12. 12.  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 Fracture 1-Year Mortality is 20-50% also a Urinary Tract Infection So you know someone in a SNF?
  13. 13.  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?
  14. 14. “Where do we go from here?”
  15. 15.  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
  16. 16.  Prior and current level function  ADLs = Activities of Daily Living 1) Eating 2) Bathing 3) Dressing 4) Toileting 5) Transferring/Walking 6) Continence The Key is ADLs
  17. 17. Hospital Street, USA RCFE-Independent Living Board & Care Land ER-Land Hospice Land Home SNF-Skilled/Custodial EntranceExit
  18. 18. Planning for Life’s Health Outcomes  Advance Directives  POLST  Talk with family/surrogate decision makers GOALS OF CARE
  19. 19. Ideal
  20. 20. Reality
  21. 21.  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 Ugly of SNF…
  22. 22.  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…
  23. 23.  Eating  Laughing  Loving  The Dark Side- being alone, feeling isolated etc… It’s a social thing…
  24. 24.  Advanced Directive  POLST  TALK TO YOUR FAMILY Must Know: Goals of Care
  25. 25.  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!
  26. 26.  Listen to your doctors as long as they are listening to you Challenges: Doctors
  27. 27.  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
  28. 28.  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
  29. 29.  Medical  Psychosocial  Financial  Loss/Grief  Dependence Challenges: Patient
  30. 30.  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
  31. 31.  Paradigm shift  SNF corporations  Public Health State/County regulators  Joint Comission  Transparency of costs Challenges: Society/Community
  32. 32. “What does love got to do with it?”
  33. 33.  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!
  34. 34.  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
  35. 35. SNF Stay Optimized! THANK YOU Questions & Discussion

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