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

 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.

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

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 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

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

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

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 PM&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 % is paid and 20% by patient PCP 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 Hospitalist 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 PCP Outpatient RehabMedicare Part B Medicaid Pay per visit PCP 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 day PCP or palliative care specialist Adapted from JAMA, 01/19/2011-Vol305, No.3 “Finding the Right Level of Posthospital Care”, Robert L. Kane, MD.

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 PCP 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.

 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.