Glossary of Terms



Transitional Care Overview

“They overmedicated me like you wouldn’t believe (in the nursing home). All they had to do was make one call to my primary care doctor.”

“They came in at 6PM and informed me that the ambulance was waiting to take me to a nursing home.” (Coleman, 2002)

(1) Definition of transitional care: a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care in the same location. Locations include hospitals, rehabilitation facilities, assisted living, long-term care facilities, physician offices and the patient’s home. (Coleman and Boult, 2003)

(2) Key components of good transitional care:

1. Patient and caregiver education/preparation

a. Involve patients/caregivers in the care plan

b. Give clear advice on management of their conditions, recognition of warning signs + symptoms, and instructions for contacting a health professional

2. Develop a comprehensive plan of care with a current problem list, medication list, allergies, advance directives/goals of care, baseline physical/cognitive function, contact information for caregivers and health professionals

3. Communicate the care plan to the receiving professionals

How often do transitions occur? (Boockvar, 2004, Landro 2006)

(3) What are the “side effects” of poor transitional care? (Coleman, 2002)

an inappropriate plan with conflicting recommendations

1. confusing and incorrect medication regimens

2. inadequate follow-up care and monitoring

3. insufficient preparation/education of the pt and caregivers

4. patient/caregiver frustration and dissatisfaction

5. increased health care utilization

(4) What is the frequency and etiology of adverse events? (Forster, 2003)

|Nearly 1 in 5 patients experience an adverse event during the transition from hospital to home |

|1/3 of adverse events are preventable |

|2/3 of adverse events are medication related |

|Effective communication can prevent adverse events |

|1/4 of patients with an adverse event post discharge are re-admitted |

Key studies:

Adverse events following discharge from the hospital (Forster 2004, 2005)

1. Adverse event = injury occurring as a result of medical management

2. Rate of adverse events 19-23%, most commonly due to an adverse drug event (ADE)

3. Pts who recalled a discussion of medication side effects had a lower risk of ADE

4. Adverse events are associated with increased utilization of health services (readmissions, ER visits, MD visits, lab monitoring)

(5) Challenges to Improving the Quality of Transitional Care (Coleman and Berenson, 2004)

• Providers are not aware of the problem or the available resources

o patients have multiple providers and no one person coordinating care

o providers fail to make appropriate referrals for home care (Bowles, 2002)

o providers are unfamiliar with the settings to which they are sending patients

• Patients are unprepared for a self-management role

o transitions are often urgent/unplanned, a time of psychosocial stress

o Poor discharge outcome are assoc with age >80, inadequate support system, multiple chronic conditions, hx of depression, mod-severe functional impairment, multiple hospitalizations in last 6 months, any hospitalization in last 30 days, fair or poor self-health rating, hx of nonadherence (Naylor, 1999)

• Institutions function in cultural and electronic isolation

• Reimbursement is not aligned to good transitional care

o little financial incentive for collaboration across sites of care

o minimal financial risk to providers who fail to ensure smooth transition

o providers are not reimbursed for time spent facilitating transfer of patient

(6) Interventions to improve care transitions:

1. Patient-centered (Coleman, 2002, 2004, 2006)

2. Provider-centered

a. Nurses (Naylor, 1999, 2000; Rich, 1995)

b. Interdisciplinary teams (Stewart, 2002)

c. Pharmacists (Schnipper, 2006; Crotty et al, 2004)

3. Most show a significant decrease in re-admission rates, cost

|*An intensive nursing intervention for CHF patients resulted in a 30% reduction in mortality and re-admission which was equal to |

|the effect of being on a beta blocker!* (Stewart, 2002) |

POLYPHARMACY

(1) Polypharmacy has multiple definitions: the concurrent use of multiple medications, prescribing more medication than clinically indicated, a medical regimen that includes at least 1 unnecessary medication or the use of 5 or more medications. (Williams, 2002)

• A 2003 survey of over 17,000 Medicare users/65+ yrs showed: (Safran, 2003)

o 46% of seniors take 5 or more medications daily

o 73% of seniors with chronic illnesses take 5+ meds daily

|What contributes to polypharmacy? |

|chronic conditions |

|multiple symptoms |

|multiple providers |

|multiple pharmacies |

|drugs administered by multiple routes |

The prescribing cascade: when a drug-related symptoms and side effects lead to the prescribing of more medications. (Williams, 2002) When an older patient presents with new signs/symptoms remember to list polypharmacy on the differential!

(2) What are the complications of polypharmacy? (Colley and Lucus, 1993; Drake and Romano 1995)

• Adverse drug events (Harris, 2006; IOM Preventing Medication Errors)

• Non-adherence

• Increased health care costs

(3) Medications associated with adverse drug events

Polypharmacy may be necessary for the optimal management of chronic disease (e.g. heart failure, diabetes) but certain classes of medications are often associated with adverse events and others are rarely indicated in the elderly

• Risk of ADE highest for steroids, anticoagulants, antibiotics, analgesics and CV medications (Forster 2005)

• The Beers criteria – a list of drugs that are potentially inappropriate in the elderly developed by a consensus panel of geriatricians and pharmacologists (Williams, 2002)

- Consider each patient individually. If the drug is necessary and the patient has tolerated it without adverse effect may continue it

- Commonly seen medications in the inpatient setting: antihistamines (benadryl, atarax), diphenoxylate (Lomotil), oxybutynin (Ditropan), ketorolac (Toradol)

(4) Interventions to decrease polypharmacy & prevent medication errors

(Williams, 2002, Colley and Lucus, 1993, Drake and Romano 1995)

Things the patient can do:

• get all medications from a single pharmacy

• keep an updated list of medications (incl OTC, topicals, inhaled meds)

• inform PMD if another provider changes medications

• throw away outdated medications

• avoid sharing medications

Things the provider can do:

• use each patient encounter as an opportunity to stream-line the medication list

• ask about adherence at each encounter and especially at care transitions

• know which medications are “inappropriate” for elderly patient

• when making medication changes, clearly explain the name, indication, and instructions for taking new meds. Discuss adverse reactions and what to do if they occur. Ask the patient/caregiver to repeat information back to you.

JCAHO has mandated medication reconciliation! (National Patient Safety Goals, 2006)

(5) Non-adherence is common and increases with polypharmacy (Safran, 2005)

|66% of seniors with chronic illnesses who lacked insurance coverage reported non-adherence |

|25% of pts did not fill at least 1 or more prescriptions due to cost |

|20% spent less on basic needs in order to afford medications |

|20% skipped doses or stopped a medicine because of side effects |

|20% stopped medicines they believed were not helping |

*Age itself is not predictive of non-adherence*(Vik, 2004)

HEALTH LITERACY

|Statistics: (IOM, 2004; Safeer and Keenan, 2005) |

|Nearly 50% of US adults lack the reading and numerical skills necessary to full understand and act on health information |

|80% of older adults have limited ability to complete health forms |

Definition of health literacy (Institute of Medicine, 2004) : the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

• Inadequate health literacy adversely affects adherence and ability to understand and effectively manage chronic illness.

• Older adults are especially vulnerable because they have lower levels of health literacy but more chronic illness and complex medication regimens (Sudore, 2006)

Consequences of inadequate health literacy

• Limited health literacy is assoc with poor understanding of chronic disease, lower self-rated health, increased hospital and ER utilization, and higher expenditures. (Sudore, 2006)

• A survey of 2923 Medicare enrollees in 4 US cities to assess the relationship between health literacy and physical and mental functioning found: (Wolf, 2005)

- Individuals with inadequate health literacy…

▪ scored lower on measures of physical and mental health

▪ reported more difficulties with ADLs/IADLs

- In multivariate models, the association between inadequate health literacy and physical function was comparable to a diagnosis of cancer and twice that of having a diagnosis of heart failure!

WHAT YOU CAN DO: (Safeer and Keenan, 2005; Sorrell, 2006)

• Routinely take the time to assess health literacy skills

- Asking about highest level of education is not sufficient

- Recognize that patients may be embarrassed to disclose limited literacy (Marcus, 2006)

- Formal tests exist but may not be feasibly administered in clinical setting

• Pay attention to behaviors that suggest limited literacy

• Avoid medical jargon

• Use pictures to enhance understanding and recall

• Ask patients to demonstrate their understanding

- Avoid yes/no questions e.g. “Do you understand what this pamphlet says?”

- Example: “Please explain to me how to take these pills.”

- Example: “Please show me how you would use this glucometer.”

• Use educational material that is written at a 6th grade level

Functional Assessment

|FUNCTIONAL ASSESSMENT | |

| | |

|ROS: |SH cont: |

|Falls “Have you fallen in the last year?” |Home environment (ask about stairs, bath equipment, rugs, lighting) |

|Urinary incontinence |Social support (ask about emergency contact, HCP) |

|“Do you ever lose urine and get wet?” | |

|Depression screen |Exam: |

|“During the past month, have you been bothered by feeling down, depressed or |Nutritional status – height/wt ( BMI |

|hopeless?” |Vision – on Jaeger card >20/40 = abnormal; can |

|“During the past month, have you had little interest or pleasure in doing things?” |also use newspaper, ID tag |

| |Hearing – whisper test |

|SOCIAL HX: (Not just tob + etoh!) |Upper extremity |

|ADLs IADLs |touch back of head w/both hands |

|Transfers Shopping |pick up pen/pencil |

|Toileting Medications |Lower extremity |

|Bathing Meal prep |Timed Get up and Go test (ask pt to rise from chair, walk 10ft, turn, return to |

|Dressing Using phone |chair and sit down) |

|Grooming Finances |Mental status – Mini-Cog 3 object recall plus clock |

|Eating Housework | |

| |Adapted from: Lachs et al. Annals of Internal Medicine 1990;112:699-706. |

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HOME CARE SERVICES

Think about ordering home care services for patients whose medical and social needs exceed their ability to access health care facilities or receive assistance from family/friends.

|Possible reasons for referral: | |Service(s) that could be provided: |

|Poorly controlled chronic illness (e.g., heart failure, |( |Vital signs monitoring, med adjustment |

|DM, HTN) | |Patient/caregiver education |

|Gait instability, frequent falls |( |PT evaluation |

| | |RN for home safety evaluation |

|Orthopedic conditions (e.g., fracture, joint replacement) | |PT/OT evaluation |

|Complex wound(s) |( |RN for dressing changes and mgmt |

|Cognitive impairment |( |OT evaluation for ADL training |

|Neurologic impairment (e.g., stroke) |( |PT/OT evaluation |

|Signs of poor nutritional status |( |Nutritionist evaluation |

|Signs of neglect or abuse |( |Home safety evaluation |

|Terminal illness |( |Home hospice |

How to make a referral for home care services:

• Who can initiate the referral: any physician (a nurse or social worker can also initiate the referral as long as a physician signs a plan of care)

• Inpatient referrals: usually involve completion of the Briggs form

• Outpatient referrals: the provider making the referral can call the home care agency directly or send/fax a plan of care. In the CLIMACS system, a provider can complete and sign the CMS 485 form which constitutes a plan of care.

• For a home attendant, the provider must complete an M11Q form every 6 months detailing the patient’s current conditions, medications, functional status and need for durable medical equipment. The M11Q is considered a physician order.

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HOME CARE GLOSSARY OF TERMS

Home Health Care: Health and social services provided in the home. Includes both skilled care and personal care. In New York State, Certified Home Health Agencies (CHHAs) provide home care services covered by Medicare, whereas Licensed Home Care Service Agencies (LHCSAs) provide private-pay home care. CASA (Community Alternative Systems Agency) is run by New York City’s Home Care Services Program and provides case management services and home attendant services for Medicaid recipients.

Examples of Medicare-certified home health agencies include: Visiting Nurse Service of New York and Metropolitan Jewish Home Care. You can look up various agencies by location and services provided on the Medicare website at: Home.asp?dest=NAV|Home|Search#TabTop

o Skilled Care: Services provided by a professionally trained individual. Examples of skilled nursing include wound care, patient education, home safety evaluation, nutrition evaluation, IV therapy, and injections. Medicare does not consider pre-pouring of medications (i.e., filling a pillbox) to be a skilled service. Other examples of skilled care include respiratory care, speech/language therapy, PT, and OT.

o Personal Care (Non-skilled or Custodial Care): Services provided by “non-skilled” individual (e.g., assistance with transferring, dressing, bathing, eating, housekeeping, laundry, shopping and cooking.)

• Home Health Aide (Nurse’s aide): A trained individual who can help with simple health-related tasks. Aides certified by the New York State Department of Health receive training in working with immobile patients, monitoring temperature and pulse rate. They can assist patients with shopping, cooking, laundry, housekeeping, dressing, bathing, and eating. They are not allowed to give medications or fill a pillbox. (More detail: An aide can direct the patient to take each day’s medication from a pillbox pre-filled by a family member.) $$ REIMBURSED BY MEDICARE, MEDICAID, SOME COMMERCIAL INSURANCES $$

• Home Attendant (Personal care worker or Companion): An individual who can provide assistance with personal care and housekeeping services only. In New York State, they receive special certification. Attendants provide assistance with ADLs and IADLs, but cannot perform health care functions like a home health aide (e.g., taking a patient’s temperature.) $$ REIMBURSED BY MEDICAID ONLY $$

• Reimbursement for home care services:

o Medicare will pay for home health care services on a part-time basis through a Medicare certified agency if the individual:

▪ Is homebound or unable to leave the home unassisted.

▪ Requires other skilled care e.g., intermittent skilled nursing care, PT or speech/language therapy. (Note: Medicare will not cover OT services alone).

▪ Under the care of a physician who signs a plan of care (the Briggs form for inpatients, CMS 485 form for outpatients).

o Medicare WILL cover: skilled care and related home health aide services on a part-time basis.

o Medicare WILL NOT cover: 24-hour-a-day care at home, homemaker services (e.g. shopping, cleaning, laundry), personal care (e.g. bathing, dressing, toileting) if there is not a related need for skilled care, or home-delivered meals

o Medicaid pays for home care services but coverage varies by state.

o Private long-term care insurance may also pay for home care services.

• Providers of skilled care:

o Registered nurses (RNs) and licensed practical nurses (LPNs): Professionals who provide skilled services e.g., injections and IV therapy, wound care, education on disease treatment and prevention, and patient assessments. RNs may also provide case management services. RNs have received two or more years of specialized education and are licensed to practice by the state. LPNs have one year of specialized training and are licensed to work under the supervision of RNs.

o Physical therapists (PTs): Professionals who work to restore the mobility and strength of patients who are limited or disabled by physical injuries through the use of exercise, massage, and other methods. PTs help to alleviate pain and restore or maintain strength and flexibility with specialized equipment. They also teach patients and caregivers special techniques for walking and transferring.

o Occupational therapists (OTs): Professionals who help individuals who have physical or cognitive problems that prevent them from performing the general activities of daily living. OTs instruct patients on using specialized rehabilitation techniques and equipment to improve their function in tasks such as eating, bathing, dressing, and basic household routines.

o Speech language pathologists (SLPs): Professionals who work to develop and restore the speech of individuals with communication disorders; usually these disorders are the result of traumas such as surgery or stroke. Speech therapists also help retrain patients in breathing, swallowing, and muscle control.

Sources:

National Association for Home care and Hospice:

New York State Dept of Health:

Medicare:

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Rehabilitation

| |Services |Eligibility Criteria | | | |

|Location |Provided | |Length of stay |Payment |Regulation |

|Acute Rehabilitation |24 hr Nursing |Tolerate 3 hrs |Varies depending on |Medicaid, Medicare |Department of Health |

|A separate institution or |Meds |therapy/day |condition and progress |Private Insurance |Requires licensure and |

|located within a hospital |Personal care |Follow simple commands |Average 2 to 6 weeks |depending on the plan |accreditation |

| |PT/OT/SLT |Ability to learn | | | |

| |Physiatrists | | | | |

| |Medical Care | | | | |

| |Social Workers | | | | |

| |Meals | | | | |

|Sub-acute Rehabilitation |24 hr Nursing |Tolerate 30 min to 2h |Varies depending on |Medicaid 100% |Department of Health |

|(SAR) |Meds |therapy/day |condition and progress |Medicare 100 % day 1 –20 |Requires licensure and |

|a.k.a skilled nursing |Personal care |Follow simple commands |Average 2 to 6 weeks |; 80% day 21-100 |accreditation |

|facility (SNF) |PT/OT | | |Private Insurance | |

|part of a long-term care |Speech/swallowing therapy (SLT) | | |depending on the plan | |

|facility |Social Work | | | | |

| |Medical Care | | | | |

| |IV antibiotics | | | | |

| |Wound care | | | | |

| |Dialysis | | | | |

| |Tracheostomy Care | | | | |

| |Tube feeds | | | | |

| |Social/recreational activities | | | | |

| |Meals | | | | |

|HOME PHYSICAL THERAPY (PT)|Increase, restore or maintain ROM,|Tolerate 30 to 60 minutes|Varies depending upon |Medicare, Medicaid, |Graduate from an accredited|

| |physical strength, flexibility, |of PT 2 to 3 times a week|condition and progress |Private Insurance |education program |

| |coordination, balance and |Follow simple commands | |Companies (usually will |Have to meet specific |

| |endurance | | |cover for short period of|licensure requirements |

| |Teach positioning, transfers, | | |time) | |

| |walking skills | | | | |

| |Prevent further decline in | | | | |

| |function by use of assistive | | | | |

| |devices | | | | |

| |Reduce pain | | | | |

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Rehabilitation continued

|HOME OCCUPATIONAL THERAPY |Assist in developing the "skills |Tolerate 30 to 60 minutes|Varies depending upon |Medicare, Medicaid, |Graduate from an |

|(OT) |for the job of living". |of OT 2 to 3 times a week|condition and progress |Private Insurance |accredited education |

| |Customized treatment programs to |Follow simple commands | |Companies (usually will|program |

| |improve ability to perform IADLS/ | | |cover for short period |Have to meet specific |

| |ADLS | | |of time) |licensure requirements |

| |Comprehensive home evaluations | | | | |

| |Adaptive equipment | | | | |

| |Usually treat conditions/ | | | | |

| |impairments of upper extremities | | | | |

| |(“above the waist”) as opposed to | | | | |

| |PT which focuses on lower | | | | |

| |extremities (“below the waist”) | | | | |

|HOME SPEECH and LANGUAGE |Perform swallow evaluations |Follow simple commands |Varies depending upon |Medicare, Medicaid, |Graduate from an |

|THERAPY (SLT) |Teach maneuvers and adaptations | |condition and progress |Private Insurance |accredited education |

| |for patients with dysphagia | | |Companies (usually will|program |

| |Speech therapy (e.g., stroke | | |cover for short period |Have to meet specific |

| |patients) | | |of time) |licensure requirements |

*Image from JAMA 2002:

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An Introduction to Housing Options

| |Services |Eligibility Criteria | | | |

|Location |Provided | |Length of stay |Payment |Regulation |

|Long-term care |Same as sub-acute rehab |Require long-term |Indefinite |Medicaid 100% |Department of Health |

|Facility a.k.a nursing| |custodial care | |Medicare 0% |Requires licensure and|

|home, skilled nursing | |Require supervision and/or| |Private Long –term care |accreditation |

|facility (SNF) | |assistance with ADLs | |insurance depending on the | |

| | |Require skilled care | |plan | |

|Assisted Living |Individual apartment |Some independence with |Indefinite |Private pay |Regulated by each |

|Facility |Meals in a common area |ADLs | |(Medicaid for rare exceptions|state |

|Free standing or |Laundry/ housekeeping |Do NOT require 24 hr | |in some states) | |

|affiliated with a |Medication management (some) |skilled care | | | |

|nursing home or |Personal care assistance (some) | | | | |

|retirement community |No skilled nursing care | | | | |

| |Services can vary | | | | |

|Retirement Communities|Individual apartment |Do not need any assistance|Indefinite |Private Pay |None because they do |

| |Recreational activities |with ADLs | | |not provide health |

|a.k.a independent |Social events | | | |care |

|living |Meals | | | | |

| |Laundry | | | | |

| |No personal care or health care | | | | |

| |is provided | | | | |

COMMUNITY RESOURCES

| | |

| |Senior Centers |

|[pic] |Senior centers function as meal sites, screening clinics, recreational centers, social service agency |

| |branch offices, mental health counseling clinics, older worker employment agencies, volunteer |

| |coordinating centers, and community meeting halls. They can provide a sense of belonging, offer the |

| |opportunity to meet old acquaintances and make new friends, and encourage individuals to pursue |

| |activities of personal interest and involvement in the community. There is usually a small fee of |

| |$1-$5 for lunch. Local example: Lenox Hill Neighborhood House Senior Center at 343 East 70th Street,|

| |open 7 days/week. To search for other senior centers by zip code, borough and services provided go to|

| | |

| |Personal Emergency Response Systems (Medical Alarms) |

| |Electronic devices, usually worn as a pendant or bracelet by the client, which can be activated at the|

| |touch of a button in emergency situations. When the alarm is activated, it sends a signal to a |

| |24-hour emergency response center where an operator attempts to establish two-way contact with the |

| |client and dispatch appropriate assistance (e.g., 911, a neighbor or a family member.) Example: New |

| |York Hospital Lifeline program 212-746-6479 (Cost $75 to set up and $40/month). |

|[pic] | |

| |Shop and Escort Programs |

| |Shop and Escort programs provide a volunteer to escort a senior to a doctor’s appointment or accompany|

| |them while grocery shopping. Local example: The Senior Companion Program relies on healthy older |

| |adults who volunteer to help homebound elderly individuals (Manhattan 212-406-5044), DOROT (see below,|

| |212-769-2850) offers an emergency food delivery service for seniors returning from the hospital. There|

| |is usually no cost for these services, but a donation of $3-$5 is suggested. |

| |Home Delivered Meals |

|[pic] |Aka the Meals on Wheels Program (212-687-1234) in NYC. When referral made, a social worker visits the|

| |individual’s home to make an assessment.  In order to qualify for home-delivered meals, a person must|

| |be at least 60 years of age and have a chronic physical disability such that the person cannot shop |

| |for food and prepare meals that meet daily nutritional needs. This service is free. To locate an |

| |agency by zip code go to: (Note: DOROT’s Nutrition Center |

| |212-769-2850 offers home-delivered Kosher meals) |

| |DOROT (University without Walls Program) |

| |A non-profit, multi-service agency whose mission is to “extend a lifeline of support to homebound and |

| |homeless elders.” Programs and services include a friendly visitors program, a shop and escort |

| |program, holiday package deliveries, an annual Thanksgiving banquet, several home meals programs, |

| |exercise classes, a homelessness prevention program, and a caregivers’ support center. The unique |

| |University Without Walls program is a continuing education and support network for homebound |

| |individuals. Classes and support groups are professionally-led and conducted over the phone using a |

| |teleconference system. Cost: $10 registration, $15/course; 212-769-2850 () |

|[pic] | |

| |Friendly Visitor and Telephone Reassurance Programs |

| |These programs provide regular personal or telephone contact for older persons who are homebound or |

| |live alone. Usually a volunteer provides the services. Besides developing friendships, perhaps a |

| |more important aspect of these programs is the volunteer’s ability to identify an individual’s needs |

| |as they occur and notify those who can help. Local example: the Elders at Home program, operated |

| |through the Stanley Isaacs Center, engages seniors in telephone conference calls for friendly chats |

| |and offers phone-based support groups. There is no fee to participate. Contact Jennifer Schneider |

| |(212) 360-7620 ext. 23 |

| |MENTAL HEALTH SERVICES: |

|[pic] |SPOP (Service Program for Older People) |

| |A non-profit community-based mental health center for older adults that provides individual and group |

| |counseling, medication management, support groups, home visits, education and bereavement support. |

| |The organization runs an adult day center, a mental health clinic, a continuing day treatment program,|

| |and a free geriatric outreach program for residents of the Upper East Side of Manhattan (including |

| |Spanish Harlem.) The clinic uses a sliding scale fee structure but does not deny anybody on the basis|

| |of ability to pay. To make a referral for the outreach program contact the Intake Worker at (212) |

| |787-7120, ext. 514. |

|[pic] |Cornell cares website () |

| |Contains practical tools, information and resources to make geriatric mental health and psychosocial |

| |assessments and interventions easier and more effective for health care providers. Includes a NYC |

| |Medicare mental health provider directory and a search tool for locating a provider by location or |

| |type of practice and geriatric psychosocial patient handouts on topics such as housing options, role |

| |changes, and supportive home services. |

|[pic] |ADULT DAY PROGRAMS |

| |Adult Day Care Centers offer social, recreational and health-related services to individuals in a |

| |protective setting who cannot be left alone during the day because of health or social needs including|

| |confusion and disability. Clients must be appropriate for the individual center. Transportation may |

| |be available within a catchment area. Depending on programs, aides may also attend with the person. |

| |Adult day centers generally operate programs during normal business hours five days a week. |

| |SOCIAL MODEL ADULT DAY PROGRAMS |

|[pic] |These structured, comprehensive programs provide a variety of social and other related support |

| |services in a protective setting during any part of a day, but less than 24-hour care. Activities may |

| |include exercise, music, arts and crafts, cultural trips, and other activities. Social, recreational |

| |and educational activities are designed to promote physical well-being, intellectual stimulation, and |

| |social interaction. Some are covered by Medicaid, and some are funded through the Department for the |

| |Aging so are free of charge. Not covered by Medicare. Examples include: Lenox Hill Neighborhood |

| |House (donation), CV Starr Adult Day Program ($68/day), Stanley Isaacs (donation for lunch). |

|[pic] |MEDICAL MODEL ADULT DAY PROGRAMS |

| |The medical model adult day cares provide additional health related services compared to the social |

| |model. Health care services provided include physical, occupational and speech therapies, medication|

| |administration, wound care, tube feeding, grooming, showering and toileting, personal care, health |

| |monitoring, and education. Often attached to a skilled nursing facility. Costs ~ $150-200/day, may |

| |have a sliding scale based on ability to pay. In addition to private pay, often covered by Medicaid |

| |but not reimbursed by Medicare. Examples: Burden Center, Jewish Home and Hospital, Amsterdam nursing |

| |home. |

| |ADULT NIGHT CARE |

| |Some programs offer services in the evenings and on weekends. In New York, ElderServe at Night (a |

|[pic] |program run by the Hebrew Home for the Aged at Riverdale) offers a nighttime program from early |

|Starry Night by Vincent Van Gough |evening to early morning for older people with sleep disturbances, agitation, confusion, and wandering|

| |behavior. These individuals may put themselves at risk in the home setting if not closely monitored |

| |throughout the night. ElderServe offers social and recreational activities as well as health care |

| |services (e.g., medication administration, tube feeding, OT, PT) and personal care. Meals are |

| |provided and transportation is available. The program serves residents of the Bronx, Westchester, and|

| |Manhattan. Covered by Medicaid and private pay. 1-800-56-SENIOR (800-567-3646) |

| |DEMENTIA RESOURCES: |

| |DAY PROGRAMS |

| |For example, the CARE Program (Center for Alzheimer’s Respite care for Elderly), a specialized adult |

| |day program for persons with memory loss from Alzheimer’s disease or related disorders run by Lenox |

|[pic] |Hill Neighborhood House. Location: All Saints Episcopal Church, 230 East 60th Street. For more |

| |information, call 212-5022, ext. 1301. |

| | |

| | |

| |NYC CHAPTER OF THE ALZHEIMER’S ASSOCIATON |

| |Offers a 24h hotline, numerous support groups, education sessions for caregivers, short-term |

| |counseling, training sessions for home care workers, and the Safe Return Program. Website has a |

| |“search for services” function to find dementia-specialized adult day care programs, home health and |

| |hospice services, diagnostic services, and legal centers by borough. |

| | |

| | |

| |SAFE RETURN PROGRAM |

| |A nationwide wanderer's safety program created by the Alzheimer's Association; provides individuals |

| |with dementia of any type with an ID bracelet, wallet card and other identifiers. Enrollment is FREE |

| |for NYC residents. Contact Elizabeth Santiago 1-800-272-3900 |

| |ELDER MISTREATMENT SERVICES |

| |Weinberg Center for Elder Abuse Prevention |

| |Offers community training programs in elder mistreatment prevention and runs a regional elder abuse |

| |shelter on the main campus of the Hebrew Home for the Aged in Riverdale. Provides emergency |

| |short-term housing, legal advocacy and support services to victims of elder abuse. To make a referral|

| |call 1-800-56-SENIOR. |

| | |

| |Community Elder Mistreatment and Abuse Prevention Program |

| |Part of the Carter Burden Center for the Aging. Can refer to the Director Ken Onaitis for assistance |

| |with safety planning, crisis counseling, court advocacy and coordination with law enforcement. (212) |

| |879-7400 ext. 116 or email onaitisk@. |

| | |

| |Adult protective services |

| |State-run service available to persons 18+ who are mentally and/or physically impaired such that they |

| |cannot manage their own resources, carry out their ADLs or protect themselves from abuse and neglect. |

| |Services include referral for medical or psychiatric evaluation, finding alternative living |

| |arrangements, petitioning for guardians and assistance in obtaining Medicaid and home care, social |

| |security benefits, and heavy-duty cleaning services. Referrals can be made by a concerned relative, |

| |friend or neighbor, medical/social work personnel, government or private agencies and the courts. The|

| |central intake unit open M-F, 9-5PM, 212-630-1853. Referrals can also be made online at |

| | |

| |NY CITY/UPPER EAST SIDE ORGANIZATIONS |

| |HealthOutreach® |

| |A free program for adults 60 and older run by NYPH offering health lectures, workshops, individual |

|[pic] |counseling, support groups, social events, caregiver assistance, the Lifeline program, geriatric care |

| |management, and help with insurance claims and benefits issues, physician referrals and prescriptions.|

| |Cornell (212) 746-4351 Columbia (212) 932-5844 |

| | |

| |Greenberg Academy for Successful Aging |

| |A joint effort between Hospital for Special Surgery and the Wright Center on Aging. Offers health |

| |education programming for adults aged 65 and older (e.g., classes on tai chi, yoga, end-of-life care |

| |planning). For info call (212) 606-1057. |

| |Public-and-Patient-Education/Outreach-Programs/Greenberg-Academy/ |

| | |

| |Lenox Hill Neighborhood House (E. 70th St and 1st Ave.) |

| |A social service and educational organization that offers a range of programs and services for older |

| |adults including 2 senior centers (E70 St and 1st, E54th and Lex), day programs, a monthly advance |

| |directives/estate planning walk-in clinic, financial management services, a caregiver support group, a|

| |transportation program, and some nursing and housekeeping services through their affiliates. Project |

| |Scope is an outreach program run by social workers that serves homebound elders. |

| |() |

| | |

| |The Carter Burden Center for the Aging (E. 77th St and 1st Ave.) |

| |A social service organization offering a range of programs and services for older adults including a |

| |senior center (The Carter Burden Luncheon Club E74th St), an elder mistreatment prevention program, a |

| |social model adult day program (CV Starr Adult Day Services E85th St), a Medicare/Medicaid assistance|

| |program, and various support groups. The Center also operates a Homebound unit run by social workers |

| |who can help develop care plans and coordinate services to help seniors remain in their homes safely |

| |and a Walk-in Unit that offers case management assistance, benefits assistance, advocacy, and |

| |supportive counseling. () |

| | |

| |Stanley M Isaacs Neighborhood Center (E. 93rd St and 1st Ave.) |

| |A community service organization at E93rd St. between 1st Ave. and FDR Drive offering a variety of |

| |senior services including Meals on Wheels, a social model adult day care, a senior center, adult |

| |education classes, cultural and educational events, and workshops. |

| | |

| | |

| |Home Visit Programs |

|[pic] | |

| |Weill Cornell Housecall Program (Upper East Side) |

| |Contact: Deirdre Mole, GNP 212-746-7000 |

| |Mt. Sinai Visiting Doctors Program (All Manhattan) 212-241-4141 |

| |Montefiore Menschel Geriatric Home Visiting Program (Bronx) |

| |Contact: P. Wald-Cagan 1-866-MED TALK |

| |St. Vincent’s (Downtown Manhattan) 212-604-3720 |

| |For an online directory of programs see the Metropolitan Area Consortium on House Call Medicine |

| |website at |

| |*(Areas served in parentheses) |

| |Private Hire Home Care Services |

|[pic] |If private insurance or Medicare or Medicaid does not cover the cost of home care services, the |

| |patient and family have to pay out-of-pocket. Most licensed home care agencies in NYC charge an |

| |hourly rate and require that an aide be hired for a minimum of 4 hours per day. Only |

| |non-agency-affiliated aides can be given permission to do certain healthcare-related services e.g. |

| |administering medications or filling a pillbox because they are considered employees of the patient or|

| |family. Examples of agencies: ElderServe (212) 746-7075, Partners in Care (888) 943-8435, Select |

| |Care (212) 505-3640, Senior Bridge (212) 994-6100 |

| |handouts/shs_homecare.pdf) |

| | |

|[pic] |Geriatric Care Managers |

| |People who are specifically trained in geriatric care management, and provide case management services|

| |on a fee-for-service basis to individual clients. Services provided usually include a comprehensive |

| |initial evaluation followed by coordination of services and care. Many GCMs have nursing or social |

| |work backgrounds. One study found the average cost of the initial assessment to be ~$175 with an |

| |hourly fee of $75. () |

|[pic] | |

| |Social Workers |

| |Professionals trained to evaluate the social and emotional factors affecting patients and provide |

| |counseling. They also help patients and their family members identify available community resources. |

| |Social workers may also serve as case managers when patients' conditions are so complex that |

| |professionals need to assess medical and supportive needs and coordinate a variety of services. |

|[pic] | |

| |Durable Medical Equipment |

| |Any type of medical equipment prescribed by a doctor for use by a patient at home. These items are |

| |reusable, and may include home hospital beds, wheelchairs, lift chairs, and oxygen equipment. Durable|

| |medical equipment may be covered by Medicare, Medicaid or private insurance. |

| |Hospice Services |

| |The hospice benefit is available to individuals who are terminally ill and have a life expectancy of |

| |six months or less; there is no requirement for the patient to be homebound or in need of skilled |

|[pic] |nursing care. A physician's certification is required to qualify an individual for the Medicare |

| |Hospice Benefit. The physician also must re-certify the individual at the beginning of each six-month |

| |benefit period. In turn, the patient is required to sign a statement indicating that he or she |

| |understands the nature of the illness and of hospice care. By signing this statement, the patient |

| |surrenders his or her rights to other Medicare benefits related to terminal illness. In most states, |

| |Medicaid covers hospice as well. Examples of organizations in New York City who provide home hospice |

| |care include: Cabrini Hospice (E19th Street), Calvary Hospital Hospice (Bronx), Continuum Hospice |

| |Care (formerly Jacob Perlow Hospice), VNS of NY Hospice Care, and Metropolitan Jewish. |

| |() |

|Other helpful websites: | |

| |NYC Department for the Aging |

| | |

| |NY State Office for the Aging |

| | |

| |Cornell Cares (patient handouts in English and Spanish) |

| | |

| |ElderCareLink (free online referral service) |

| | |

| |ElderCare Locator (govt sponsored free online referral service) |

| | |

| |Hospice & Palliative Care Association of New York State |

| | |

*All images from ; all websites accessed October 13, 2006.

MEDICARE FACT SHEET

1. What is Medicare?

▪ A federal health insurance program enacted in 1965.

2. Who qualifies for Medicare?

▪ Persons age 65 or older and eligible for Social Security payments.

▪ Persons under age 65 who are receiving social security cash payment because of disability are eligible after two years.

▪ Persons with end-stage renal disease or Amyotropic Lateral Sclerosis.

3. What is the original Medicare plan?

▪ A traditional pay-per-visit arrangement.

▪ Patients can go to any doctor, hospital, or other health care provider who accepts Medicare.

▪ Patient is responsible for the deductible and a coinsurance.

4. What does each beneficiary pay for Medicare?

▪ PART A: There is no premium for Part A. There is a $992 deductible cost for a hospital stay and is based on the “benefit period.”

▪ PART B: There is a $93.50 monthly premium for individuals who earn $80K or less/yr, a $131 deductible, and covers 20% of approved amount after deductible. (As of 1/1/07, Part B premiums income-based and are higher for those with incomes over $80K).

▪ PART D: Beneficiary premiums and deductibles vary depending on which private plan is chosen – the average national premium is $27.35; the highest possible deductible is $250.

5. What is covered under Part A?

▪ Inpatient hospital care

▪ Inpatient care in a skilled nursing facility

▪ Home health care

▪ Hospice care

6. What is covered under Part B?

▪ Physician’s services

▪ Outpatient hospital care

▪ Diagnostic tests

▪ Ambulance services

▪ Durable medical equipment (partial payment)

7. What is covered under Part D?

▪ Prescription medications

8. What is a Medigap plan?

▪ Several insurance companies sell supplemental coverage that help cover Medicare deductibles, coinsurance and some additional benefits.

9. What is NOT covered under Medicare?

▪ Acupuncture

▪ Dental care

▪ Care outside of the United States

▪ Chiropractic services (except to correct a subluxation)

▪ Cosmetic surgery

▪ Custodial care (unless skilled nursing care is provided)

▪ Eyeglasses (except after cataract surgery)

▪ Hearing aids (except certain implants for extreme hearing loss)

▪ Long-term care

▪ Personal Care

▪ Private duty nursing

Sources:



MEDICAID FACT SHEET

1. What is Medicaid?

▪ A government assistance program that provides comprehensive health care coverage for prescription drugs, physicians’ services, hospital, nursing home and home care.

▪ The federal, state and local governments all have agencies responsible for the administration of Medicaid.

2. What does a beneficiary pay for Medicaid?

▪ No money is exchanged. Medicaid patients do not pay for services, except for co-payments on prescription drugs, inpatient care, and various other services.



3. Who qualifies for Medicaid?

▪ The category the individual falls into determines criteria for eligibility.

1. BAD -- Blind, aged (65+), or disabled. Disability is defined as the “inability to engage in substantial, gainful employment” because of a physical or mental impairment that is expected to last at least 12 months or ends in death.

2. Children and their Parents/Caretakers -- All persons under age 21, pregnant women, and parents/caretaker relative of children under 21. Children under age 18 and pregnant woman have higher income limits than Category A and no resource limits. Parents/caretaker relatives and children ages 18-21 have same income and resource limits as Category A.

3. Single and married adults with no children -- Lower income and resource limits than Categories A & B, not eligible for “spend-down” of excess income.

▪ In order to be eligible for Medicaid, a client must meet three* eligibility criteria:

A. Citizenship -- Must either have U.S. citizenship, a greed card or be a “Person Residing Under Color of Law” (PRUCOL). (PRUCOL is a broad category that includes many documented immigrants who do not have green cards but have some application pending with the immigration service.) Pregnant women may receive Medicaid even when undocumented.

B. Residence -- A permanent resident is a person living in New York State who intends to stay in the state. There is no duration requirement for residency in New York State.

C. Financial Need – Varies according to category.

Resources and Income for Blind, Aged & Disabled, Individuals & Parents/Caretaker Relatives of Children under 21, and Children ages 18-21:

|Family Size |1 |2 |3 |4 |5 |6 |Each add’l |

| | | | | | | |person |

|Monthly Income |$700 |$900 |$1100 |$1109 |$1117 |$1134 |$142 |

|Resource Level |$4200 |$5400 |$6600 |$6650 |$6700 |$6800 |$850 |

Income and Resource Levels are subject to yearly adjustments. One may also own a home, a car, and personal property and still be eligible. The income and resources of legally responsible relatives in the household will also be counted.

*D. Drug and ETOH screening -- Single Persons and childless couples under age 65 must also cooperate with drug and alcohol screening in addition to criteria A-C.

4. What services are covered by Medicaid?

▪ hospital inpatient and outpatient services

▪ laboratory and X-ray services

▪ treatment and preventive health and dental care (doctors and dentists)

▪ care in a nursing home

▪ care through home health agencies and personal care

▪ treatment in psychiatric hospitals (for persons under 21 or those 65 and older), mental health facilities, and facilities for the mentally retarded or the developmentally disabled

▪ family planning services, prenatal care

▪ medicine, supplies, medical equipment, and appliances (wheelchairs, etc.)

▪ transportation to medical appointments, incl. public transportation, car mileage, ambulette

▪ emergency ambulance transportation to a hospital

▪ some insurance and Medicare premiums

5. Medicaid Utilization Threshold (MUTS) -- Limits on the number of certain outpatient services that a person can receive in one year (e.g., 10 visits to a doctor; 40 prescriptions). Need to submit override request.

6. Medicaid Surplus or Spend-down program -- If applicant’s net monthly income is above income limit he/she must incur medical expense equal to or greater than monthly surplus. Note that the expense need only be incurred, not paid, so a bill for services is enough to meet the spend-down even if the patient does not pay the bill.

7. Recertification -- Most often, Medicaid is authorized for up to 12 months. Procedure varies, depending on category. Blind, aged, or disabled (BAD) recertify by mail-in process. Other clients must recertify at a face-to-face hearing.

Sources:

NY State Dept of Health

Selfhelp Community Services

REFERENCES

Transitional Care:

Boockvar et al. Patient Relocation in the 6 Months after Hip Fracture: Risk Factors for Fragmented Care J Am Geriatr Soc 2004;52:1826-1831.

Bowles et al. Patient characteristics at hospital discharge and comparison of home care referral decisions. J Am

Geriat Soc 2002;50:336-342.

Coleman et al. Development and Testing of a Measure Designed to Assess the Quality of Care Transitions. International Jour of Integrated Care 2002;2:1-8

Coleman et al. Preparing Patients and Caregivers to Participate in Care Delivered Across Settings J Amer Geriatr Soc 2004;52:1817-1825.

Coleman and Berenson Lost in Transition: Challenges and Opportunities for Improving the Quality of Transitional Care Ann Intern Med 2004;140:533-536.

Coleman and Boult. Improving the quality of transitional care for persons with complex care needs. J Amer Geriatr Society 2003;51:556-557.

Crotty et al. Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Am J Geriatr Pharmacother 2004(4): 257-64. (Abstract only)

Forster et al. Adverse Events among Medical Patients after Discharge from Hospital CMAJ 2004;170(3):345-9.

Forster et al. Adverse Drug Events Occurring following Hospital Discharge J Gen Intern Med 2005; 20:317-323.

Forster et al. The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital Ann Intern Med. 2003;139:161-167.

Landro, Laura. Hospitals Combat Errors at the 'Hand-Off' The Wall Street Journal. June 28, 2006.

Naylor et al. Comprehensive discharge planning and home follow-up of hospitalized elders. JAMA 1999;281:613-620.

Naylor, Mary D. A Decade of Transitional Care Research with Vulnerable Elders. Jour of Cardiovascular Nursing 2000;14(3):1-14.

Rich et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure NEJM 1995;333:1190-5.

Schnipper et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med 2006;166:565-571.

Stewart, S and Horowitz, J. Home-based intervention in congestive heart failure: Long-term implications on readmission and survival. Circulation 2002;105:2861-2866.

Polypharmacy

Colley and Lucus. Polypharmacy: The cure becomes the disease. J Gen Intern Med 1993;8:278-283.

Drake and Romano. How to protect your older patient from the hazards of polypharmacy. Nursing June 1995:34-39.

Forster et al. Adverse Drug Events Occurring following Hospital Discharge J Gen Intern Med 2005; 20:317-323.

FAQs for the 2006 National Patient Safety Goals. Accessed online July 24, 2006.

Harris, Gardiner. Report finds a heavy toll from medication errors. The NY Times July 21, 2006.

Preventing Medication Errors: Quality Chasm Series. catalog/11623.html Accessed online July 24, 2006.

Safran et al. Prescription Drug Coverage and Seniors: Findings from a 2003 National Survey. Health Affairs April 19, 2005. cgi/content/abstract/hlthaff.w5.152v1 Accessed online on July 24, 2006.

Vik et al. Measurement, correlates, and health outcomes of medication adherence among seniors. Ann Pharmacother 2004;38:303-12.

Williams, Cynthia. Using medications appropriately in older adults. Am Fam Physician 2002;66:1917-24.

Health literacy

Institute of Medicine. Health literacy: a prescription to end confusion. April, 2004. Report accessed online July 25, 2006 at: 3775/3827/19723/19726.aspx

Marcus, Erin. The Silent Epidemic –The Health Effects of Illiteracy. N Eng J Med 2006;355:339-341.

Safeer and Keenan. Health literacy: The gap between physicians and patients. Am Fam Physician 2005;72:463-8.

Sorrell, Jeanne. Health literacy in older adults. Journal of Psychosocial Nursing 2006;44:17-20.

Sudore et al. Limited literacy in older people and disparities in health and healthcare access. J Am Geriatr Soc 2006;54:770-776.

Wolf, et al. Health literacy and functional health status among older adults. Arch Intern Med. 2005;165:1946-1952.

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