1. Vinh Nguyen, MD, MBA Assistant Clinical Professor Division of Geriatric Medicine and Gerontology Department of Family Medicine University of California, Irvine

2.  Functional tools for assessing the older adult.  Using tools to work on your plan of care.  Understand physical performance tests pertinent to the older adult.  Know different levels of care available.  Understand some basics of CMS coverage for resources.  Use knowledge of levels of care to optimize your patient outcomes.  Plan ahead for patient disposition planning.

3.  Activities of Daily Living  Feeding  Grooming  Continence  Toileting  Ambulation  Dressing  Bathing  Instrumental Activities of Daily Living  Telephone  Cooking  Housework  Laundry  Transportation  Shopping  Medications  Finances

4. Image from: http://consultgerirn.org/uploads/File/trythis/try_this_23.pdf

6.  Not just T/E/D  Gather a thorough social history  Family  Caregiver assistance  Caregiving for others  Home setting  Apartment/Condo/Home  Number of stories  Steps in or out  Safety at home  Language and culture  Education  Profession or prior work

8.  Gait  Get up and go test  10 feet  Time?  Gait speed  >0.8-0.9 m/s: community independence  >0.6m/s: community ambulation sans WC  Tinetti Balance and Gait  Grip strength

10.  Post hospitalization AKA “Disposition”  Multi-disciplinary approach  Physical/Occupational/Speech Therapy  Social work  Patient’s wishes  Family and friends  Planning, planning, planning…

12. TypeDescriptionPayorBasis for Medicare Payment Cost Range $ per dayPhysician Type Acute Inpatient Rehab3 hours of PT/OT per day. High intensity rehabilitation. Medicare Part A Medicaid Payment per episode of care based on complexity 1000-2000PM&R Skilled Nursing FacilitySkilled needs can include variety of things including medications, wound care, rehab, etc. Medicare Part A Medicaid Daily rate, first 20 days paid by Medicare then day 21 to 100 80% is paid and 20% by patient. 150-300PCP Long-term acute care hospital Medicare facility for handling complex patients such as ventilator care/weaning, critical care patients needing more frequent physician followup Medicare Part AMedicare Diagnosis Related Group 1500-3000Hospitalist Home health careMedicare certified care run by nurses as well as PT/OT/ST/SW Medicare Part A (DME on Part B) Payment per episode of care based on complexity 100-300PCP Outpatient RehabMedicare Part B Medicaid Pay per visit100-200PCP Hospice and Palliative Care Terminal illness with focus on nonhospital care and symptom management AND active support like hospicebut without expectation of avoiding further medical care. Medicare Part A Medicare Part B Payment per day200-300PCP or palliative care specialist Adapted from JAMA, 01/19/2011-Vol305, No.3 “Finding the Right Level of Posthospital Care”, Robert L. Kane, MD.

13. TypeDescriptionPayorBasis for Medicare Payment Cost Range $ per dayPhysician Type Home care/Personal care Services for frail persons needing help with ADL or IADLs Medicaid. Ex. IHSSPer hour payment75-150PCP Nursing HomeCertified for long term care. Special units? MedicaidPayment per day75-300PCP Assisted livingInstitutional care with apartment like living quarters and some assistance on a “a la carte” basis. Medicaid (in some states with vouchers) Payment per day/month 60-300PCP Day care or adult day health centers Community faciltiies for centralized care for various periods of the day. Medicaid (some states)Payment per use60-120PCP Adult foster careSmall group homes with care by nonprofesionals Medicaid (some states)Payment per month50-100PCP Independent livingRoom and board and some housekeeping. Community activities and amenities like meals. None50-100PCP Board and careVarient of independent living, with room and some meals NonePCP Adapted from JAMA, 01/19/2011-Vol305, No.3 “Finding the Right Level of Posthospital Care”, Robert L. Kane, MD.

15.  Current and prior level of function  Therapy needs  Psychiatric care needs  Expectations  Finances  Social support  Resources such as Center for Medicare/Medicaid Services and Veterans Affairs. Also state and county resources.