Optimizing a SNF Stay

1. Welcome to
Optimizing a SNF Stay
Khai Nguyen, MD, MHS, HMDC
October 24, 2015
UCSD 2nd Annual Geriatric Symposium

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.  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.  You!
 Patient
 Prospective Patient
 Family/Friends
 DPOA/Surrogate Decision
Maker
 Clinicians/Providers
 RCFE/SNFs
Intended Audience

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.  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.  It takes a village…
Why do we even have SNFs?

8.  Medicare
 Medicaid (Medi-Cal)
 Private Insurance
 Out-of-Pocket
Who Pays for a SNF?

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.  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. So why are you at this talk?

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.  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. “Where do we go from here?”

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.  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. Hospital Street, USA
RCFE-Independent Living
Board & Care Land
ER-Land
Hospice Land
Home
SNF-Skilled/Custodial
EntranceExit

18. Planning for Life’s Health Outcomes
 Advance Directives
 POLST
 Talk with family/surrogate decision makers
GOALS OF CARE

19. Ideal

20. Reality

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…

25.  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…

26.  Eating
 Laughing
 Loving
 The Dark Side- being alone, feeling isolated etc…
It’s a social thing…

27.  Advanced Directive
 POLST
 TALK TO YOUR FAMILY
Must Know: Goals of Care

28.  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!

29.  Listen to your doctors as long as they are listening to
you
Challenges: Doctors

30.  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

31.  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

32.  Medical
 Psychosocial
 Financial
 Loss/Grief
 Dependence
Challenges: Patient

33.  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

34.  Paradigm shift
 SNF corporations
 Public Health State/County regulators
 Joint Comission
 Transparency of costs
Challenges: Society/Community

35. “What does love got to do with it?”

36.  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!

37.  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

38. SNF Stay Optimized!
THANK YOU
Questions & Discussion