1. Team Based Admission Assessment Cheryl Boldt R.N. Cheryl Boldt R.N. Senior Consultant Maun-Lemke, Inc clboldt@attglobal.net www.clintmaun.com 1-800-356-2233 1-605-351-8547

2. Nursing Facility Action Plan Work with “language” of Hospital Discharge Planners and Physicians over timeWork with “language” of Hospital Discharge Planners and Physicians over time Work with “knowledge base” and “language” of Facility StaffWork with “knowledge base” and “language” of Facility Staff Team based admission assessment shortly after admission to establish realistic Discharge Date and Destination and ARTICULATE needsTeam based admission assessment shortly after admission to establish realistic Discharge Date and Destination and ARTICULATE needs Ongoing Communication of Discharge Date and Destination to resident, family, all staff and MDOngoing Communication of Discharge Date and Destination to resident, family, all staff and MD SAFELY TRANSITION the Resident to the next level of care per the plan and Follow-UpSAFELY TRANSITION the Resident to the next level of care per the plan and Follow-Up Work on “Network Culture Change” to achieve safe and well orchestrated transfersWork on “Network Culture Change” to achieve safe and well orchestrated transfers

3. Work with “language” of Physicians and Hospital Discharge Planners.

4. Hospital Discharge Planning ACUTE HOSPITAL Example: You only need to go to the Nursing Home for…1week, 2 weeks.Example: You only need to go to the Nursing Home for…1week, 2 weeks. The Hospital Discharge Planner is trying to facilitate the resident leaving the hospital and there are time constraintsThe Hospital Discharge Planner is trying to facilitate the resident leaving the hospital and there are time constraints A short time frame in the Nursing Facility, while it may be unrealistic, “seems” to be more readily accepted by residents and families at this point.A short time frame in the Nursing Facility, while it may be unrealistic, “seems” to be more readily accepted by residents and families at this point.

5. SUGGESTED Language for Discharge Planners  “Each patient is unique and the time it takes to recover varies”  “The _______Facility has a team of experts who will assist you in establishing a good treatment plan based on your condition and circumstances”  “We want you to SAFELY TRANSITION to your desired destination”  “ It is understandable to want to be at home, and we know you want to do well at home and prevent any further hospitalizations.

6. Work with “knowledge base” and “language” of all facility staff.

7. Work with “knowledge base” of all facility staff! Knowledge of “the system” in regards to various options for care and servicesKnowledge of “the system” in regards to various options for care and services Knowledge regarding payment for care and services at the various provider locationsKnowledge regarding payment for care and services at the various provider locations Assure information shared between agencies/organizations/facilities is shared with the front line…Assure information shared between agencies/organizations/facilities is shared with the front line…  TRANSFER FORMS  YA’LL COME SHIFT REPORTS

8. Example “Language” of Nursing Facility Staff “Our team of experts have extensive experience working with people who have been in the hospital”“Our team of experts have extensive experience working with people who have been in the hospital” You need the “appropriate LENGTH OF STAY for your condition and circumstances to assure successYou need the “appropriate LENGTH OF STAY for your condition and circumstances to assure success “Discontinue” therapy instead of “DISCHARGE” from therapy.“Discontinue” therapy instead of “DISCHARGE” from therapy. “Transition you to rehabilitation nursing to assure you maintain the skill level you achieved in therapy (REHAB LOW RUG)“Transition you to rehabilitation nursing to assure you maintain the skill level you achieved in therapy (REHAB LOW RUG) We know you want to SAFELY TRANSITION to _______ and I see your planned discharge date is _________.We know you want to SAFELY TRANSITION to _______ and I see your planned discharge date is _________. We know you want to be successful when you go home and avoid re-hospitalization.We know you want to be successful when you go home and avoid re-hospitalization.

9. Team Based Admission Assessment

10. Set aside a designated time daily (M-F)Set aside a designated time daily (M-F) 1 hour max1 hour max Social Services, Dietary, Recreation Therapy ask their “questions”Social Services, Dietary, Recreation Therapy ask their “questions” Nursing presents “identified” risksNursing presents “identified” risks Therapy presents info to date and asks remaining questionsTherapy presents info to date and asks remaining questions Team establishes realistic LOS/ DATE of Discharge/ Destination with resident/ family and is able to ARTICULATE needsTeam establishes realistic LOS/ DATE of Discharge/ Destination with resident/ family and is able to ARTICULATE needs Team Communicates Discharge Destination and DATETeam Communicates Discharge Destination and DATE PILOT and go from there to “troubleshoot” barriersPILOT and go from there to “troubleshoot” barriers

11. What we need to do better Not expect Therapy to be the only driver of length of stay for Medicare A in a Skilled Nursing Facility.Not expect Therapy to be the only driver of length of stay for Medicare A in a Skilled Nursing Facility. Nursing needs to get more involved with skilled assessment and care planning inclusive of teaching and trainingNursing needs to get more involved with skilled assessment and care planning inclusive of teaching and training Utilization of Rehab or Restorative Nursing at the end of the stay to establish resident’s ability to maintain skillsUtilization of Rehab or Restorative Nursing at the end of the stay to establish resident’s ability to maintain skills Articulate to residents and family about our expert opinion of what is needed to achieve a safe transition.Articulate to residents and family about our expert opinion of what is needed to achieve a safe transition. Support skilled services with required documentation for Medicare/InsuranceSupport skilled services with required documentation for Medicare/Insurance Get the Home Care, A.L.F. or Independent Living Staff involved earlierGet the Home Care, A.L.F. or Independent Living Staff involved earlier

12. Master Discharge Calendar

13. Ongoing Communication of Discharge Date and Destination to family, resident, MD, all staff.

14. Communication of Discharge Date and Destination How to we reinforce and communicate the DDD to Family/Resident ongoing?How to we reinforce and communicate the DDD to Family/Resident ongoing? How does the front line know the DDD?How does the front line know the DDD? How does the MD become informed of the DDD so he/she can support the plan and not discharge too earlyHow does the MD become informed of the DDD so he/she can support the plan and not discharge too early

15. Safely transition the resident to the next level of care or location per the plan – Then “follow-up”.

16. Example: Safe Transition from SNF “We wish to provide you with the best possible program to assure your safe transition to the living situation you have chosen. Our professional staff will provide the environment you need to assure a successful return home or successful transition to a new or different living situation. Making this move with confidence in your new skills will decrease the stress you may be feeling regarding your current disability or illness.” “We wish to provide you with the best possible program to assure your safe transition to the living situation you have chosen. Our professional staff will provide the environment you need to assure a successful return home or successful transition to a new or different living situation. Making this move with confidence in your new skills will decrease the stress you may be feeling regarding your current disability or illness.”