Securing the Right Level of Care After Discharge
Optimal Care Planning to Reduce Hospital Readmissions
Matching the level of care to your patient's needs after discharge is critical to lowering readmissions.
Consider Jenny Jones, a 71-year-old woman who lives with her 69-year-old sister, Pat. Jenny has multiple medical conditions and is currently hospitalized.
She has severe osteoporosis with spinal compression fractures that make it painful to move. But the fractures are not what led to her hospitalization. She is here because she can't breathe. Congestive heart failure (CHF) has caused a massive fluid buildup in her body and lungs.
Poor disease management is trapping Jenny in a cycle of recurrent admissions. If she takes diuretic medications regularly, her body can maintain fluid balance. But she can't keep up with them at home; she can't walk to the bathroom independently, and Pat can't help her get there as often as she needs to.
Jenny needs more help. Her fractures are not going away, and neither is her CHF. But getting that help is not straightforward. She refuses to go to a skilled nursing facility. Even if she was willing, she doesn't have insurance coverage for more than a short stay.
Jenny's story is all too familiar to most hospital case managers. These teams help patients navigate the caregiving needs of numerous complex medical conditions daily. Over 1 million hospital admissions happen annually in the United States for CHF alone. Readmission is rampant, with 1 in 4 patients returning to the hospital within a month of discharge.[1],[2]
Caregiving in the Community
Over 65 million people, or 29% of the population of the United States, care for family members and close friends who are disabled, elderly, or living with chronic illness, like Jenny.[3] They spend an average of 20 hours a week caregiving, balancing it with full-time jobs, caring for children, and meeting the demands of their daily lives.
Among adults living at home with caregiving needs, 78% have no help beyond family and friends. Family caregivers can experience high levels of burnout.[4] Often, the patient's needs are too much for the family to handle, leading to hospitalizations and rehospitalizations that are potentially preventable.
Determine the Right Level of Care
Multiple factors contribute to choosing and securing a higher level of care, including:
The patient's ability to perform activities of daily living (ADLs), including bathing, dressing, toileting, and preparing meals
The patient's needs for skilled nursing, including wound care, physical therapy, and intravenous medication
Availability of help at home and the ability of caregivers to meet the patient's needs
The patient’s beliefs and wishes, including cultural and spiritual considerations
The patient’s financial situation, including assets and insurance coverage
When evaluating your patient’s need for a higher level of care, check with your state’s Department of Health and Human Services (DHHS) [PS1] for evaluation requirements.
The Centers for Medicare and Medicaid cover long-term care in cooperation with each state's DHHS[5] for patients with medical and financial need. To demonstrate medical qualification, use the assessment tools provided by your state’s DHHS.
Overcoming Barriers
Evaluating the right post-discharge level of care is standard practice in hospitals nationwide, but significant barriers to securing that care exist.
Those barriers can seem insurmountable, and helping patients overcome them requires a time investment and clear communication.
Follow these steps to optimize care planning:
Clarify Options
Most patients and their families are not familiar with the available options. They may have a vague concept of nursing home care and not much more. Give your patient a thorough overview of care options that could fit their needs, including:
Long-term acute care. Designed for patients needing acute care for an extended time, generally over 25 days.
Inpatient rehabilitation. Intensive, short-term therapy to improve function.
Transitional care. A step between acute care and a skilled nursing facility.
Skilled nursing. Care for patients with a daily need for a skilled nursing service.
Custodial care. Care covering ADLs but not skilled nursing. This type of care is what many think of as a nursing home.
Home health. Care for patients who need a skilled nursing service and are homebound.
Hospice. End-of-life care that is focused on comfort and includes ADLs and skilled nursing.
Assisted living. Community care that provides varying help with ADLs, including meals and transportation, and can include personal care and medication management.
Group homes. An alternative for people with long-term disabilities who require continuous help with ADLs.
Home care agency. Provides caregivers to help with non-skilled ADLs in the home.
Private hire. Caregivers employed directly by the patient. This option can be more economical than going through an agency, but it requires managing employment.
Untangle Insurance Coverage
Several types of insurance may pay for long-term care. The yearly cost of a private room in a nursing home providing custodial care is around $100,000 in the United States.[6] Because of this high cost, coverage is often partial and shared between more than one payer.
Medicare and Medicaid. Medicare covers the first 20 days of skilled nursing care and partially covers days 21-100 but does not cover after that.[7] Medicaid covers long-term care for those who meet financial limits.[8]
Private insurance. Depending on the plan, private insurance may help pay for some nursing home costs.
Long-term care insurance. If the patient has long-term care insurance, they can usually qualify for custodial care.
Veterans Affairs (VA) benefits. Senior living is covered through VA benefits.
Life insurance. Patients can surrender certain life insurance policies at cash value to help cover costs.
Nursing homes may be able to bill separately for medical and personal care so covered medical expenses can be billed to insurance if there is no coverage for personal care.[9]
Use Financial Planning
Millions of Americans have no coverage for long-term care. Medicaid covers most, and sometimes all, nursing home costs and covers forms of home care.[10],[11] But if patients have no coverage from other sources and more income and resources than the Medicaid limits, they must use personal resources to pay for care until their assets reach Medicaid qualification levels.
Examples of assets include savings, pensions, retirement income, stocks, land, vehicles, and home sale proceeds.
Managing assets can get complex. In Jenny and Pat's case, some are co-owned between siblings. Some circumstances could allow Jenny to transfer her ownership to Pat. They would benefit from a meeting with a financial adviser specializing in Medicaid planning.
Address Emotional Barriers
Patients are often reluctant to accept care or to make drastic changes in their lives to receive it.
Like Jenny, their desire to keep living at home may be stronger than the desire to stay well. They may object to caregivers coming into their home for security reasons. It can also be awkward for a patient to get personal care from someone they don't know, and they may believe that no one will understand them and their preferences as well as a trusted family member.
Some ways to overcome these barriers include:
Hold frank discussions about the need for care. A trial period may be an excellent way to start without committing to a significant change.
Facilitate communication between family members about levels of burnout and their ability to meet the patient’s needs.
Examine options the patient is more comfortable with, such as home care versus nursing home care.
Explore alternative ways to take burdens off the caregiver. Starting with housekeeping help rather than personal care may relieve some of the load on caregivers of patients reluctant to accept personal care.
Making a Plan
In an ideal world, patients who need long-term care could get it easily, but in reality, no single solution will work for everyone.
To meet Jenny’s level of need, considering her financial and emotional concerns, the pathway to better care could look like this:
Ensure Jenny and Pat fully understand the available resources that match Jenny's needs: unskilled help for ADLs.
Because Jenny wants to remain in her home, explore home-care options.
After evaluation, Jenny does not have insurance coverage for care in the home, but she could get coverage if she qualified for Medicaid.
Help Jenny and Pat meet with a financial planner to examine their assets.
Pat and Jenny will pay from Jenny's assets for in-home care through an agency. They could save money hiring an aide directly, but navigating hiring, payroll, taxes, and background checks is too much for Pat.
When Jenny's assets reach qualifying levels, she will apply for and receive coverage through Medicaid.
To reduce readmissions, supporting your case management team is essential. With strategic care planning, patients can make informed decisions to get the care they need to manage their medical conditions. Better daily management will help them break free of the rehospitalization cycle and have better outcomes.
References:
[1] Ambrosy AP, Fonarow GC, Butler J, et al. The global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries. J Am Coll Cardiol. 2014;63(12):1123-1133. doi:10.1016/j.jacc.2013.11.053
[2] Madanat L, Saleh M, Maraskine M, Halalau A, Bukovec F. Congestive heart failure 30-day readmission: Descriptive study of demographics, co-morbidities, heart failure knowledge, and self-care. Cureus. 2021;13(10):e18661. doi:10.7759/cureus.18661
[3] Caregiver Statistics. Caregiver Action Network. Published June 10, 2015. Accessed December 2, 2023. https://www.caregiveraction.org/resources/caregiver-statistics
[4] Schulz R, Sherwood PR. Physical and mental health effects of family caregiving. Am J Nurs. 2008;108(9 Suppl):23-27; quiz 27. doi:10.1097/01.NAJ.0000336406.45248.4c
[5] CMS/CM/PCG/DPIPD. Medicare-Required SNF PPS Assessments. Cms.gov. Accessed December 2, 2023. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/SNF-PPS/SNFAssessHTML022817f.html
[6] Koop C. Average Cost of Long-Term Care: A State-by-State Guide to Senior Care in the U.S. Aplaceformom.com. Published September 15, 2023. Accessed December 3, 2023. https://www.aplaceformom.com/caregiver-resources/articles/average-cost-long-term-care
[7] What Medicare covers. Medicare.gov. Accessed December 2, 2023. https://www.medicare.gov/what-medicare-covers
[8] Beneficiary Resources. Medicaid.gov. Accessed December 2, 2023. https://www.medicaid.gov/about-us/beneficiary-resources/index.html
[9] Whitley M. How to Pay For a Nursing Home: Know Your Options. Aplaceformom.com. Published November 2, 2023. Accessed December 2, 2023. https://www.aplaceformom.com/caregiver-resources/articles/pay-for-nursing-home-care
[10] Institutional Long Term Care. Medicaid.gov. Accessed December 3, 2023. https://www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/index.html
[11] Home & Community Based Services. Medicaid.gov. Accessed December 3, 2023. https://www.medicaid.gov/medicaid/home-community-based-services/index.html
[PS1]Montana is the only state I found that had the P (for Public)
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