INDEPENDENT HEALTH



KALEIDA HEALTH

SUBACUTE PARTNERS PROGRAM

AND

AFTER HOURS CARE SUPPORT PROGRAM

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Kaleida’s Patient Management Services are under the direction of Dr. Fredric M. Hirsh, Medical Director of Managed Care and Gina Gray, Vice President of Patient Management Services.

PURPOSE

The purpose of the Sub-acute Partners and After Hours Care Support Program is to offer alternatives for adult inpatient care (subacute/long term care/home care) to patients and avoid unnecessary hospitalizations. This program should offer opportunities for alternatives to acute inpatient care, reduce length of stay (LOS) for inpatient care, improve the quality of care in sub-acute and skilled nursing facilities, reduce re-admissions to the hospital, and generally provide a continuum of care for patients treated in the Kaleida Health System.

OBJECTIVES

• Provide the most appropriate and cost-effective level of care.

• Service all patients regardless of their health insurance.

• Kaleida currently has contract agreements with Independent Health and Blue Cross.

*Other insurers not excluded.

(All patients with HMO coverage do not require an inpatient stay prior to placement in an alternative setting. Patients with traditional Medicare require a 3 day inpatient stay for a covered service prior to placement in an alternative setting. An exception for Medicare occurs when the patient has been hospitalized within the previous 30 days for a similar diagnosis. The 3 day inpatient stay requirement is then waived)

( Develop a delivery system of Kaleida credentialled geriatricians and physiatrists to

provide care when patients are no longer in inpatient care settings

( Develop protocols for care in the partner facilities

( Improve communication regarding patient care and communication issues

SERVICES PROVIDED

• Placement (subacute, rehabilitation, long term care)

• Linkages to Community Services

Kaleida Health has social workers/supervisors on call after hours. They will not be on-site. Therefore, any need for appropriate services will be determined via phone consultation. If on-site consultation is necessary, it will be at the discretion of the on-call supervisor.

THE NETWORK

Kaleida Health is a Comprehensive Delivery System comprised of a variety of Acute, Subacute and Long Term Care facilities within our network.

Kaleida Health Division of Long Term Care

*Deaconess

(LTC/Subacute)

*Millard Fillmore

(LTC/Subacute)

*DeGraff

(LTC/MRU/Subacute)

*Waterfront

(LTC/Subacute)

*Buffalo General

(Acute Rehab)

*Advanced Home Care

In addition, Kaleida has developed geographic partnerships with five area facilities:

South Region:

Autumnview – Hamburg, NY

East Region

Greenfield – Lancaster, NY

North Region:

Beechwood – Getzville, NY

Williamsville Suburban – Williamsville, NY

Oakwood – Williamsville, NY

Quality continuous care will be maintained within the Kaleida System and partnering facilities and patient care will be managed by our Kaleida staffed Geriatricians.

REFERRAL PROCESS

To make a referral for inpatients please consult the discharge planning/social work department. Your patients will be offered alternative levels of care within Kaleida’s subacute and long term care facilities or within an appropriately located partner facility, depending upon bed availability. As always, the patient of family may select any other facility of their choice, and patient management will assist in achieving placement in such facility.

To make a referral when the patient does not require an acute inpatient stay you only need to follow two simple steps:

1) Patient will be evaluated by physician in the ED or other settings as appropriate

2) *ED physician pages Kaleida on-call Social Worker for phone consultation/assistance.

OR

A) FOR IHA PATIENTS

*Private Practicing Physicians should contact IHA’s Case Management Department #635-3523, Monday-Friday, 8am-5pm or Telesource after 5 pm. #1-800-501-3439.

B) FOR UNIVERA PATIENTS

Please call pager number 443 9929. A Univera Care Manager will return your page and assist with placement efforts

C) FOR BLUE CROSS PATIENTS.

Please contact Community Blue’s Care Management Department by calling 884 2942. After hours calls will be forwarded to on-call nurse

The Kaleida on-call worker will make every effort to place patient in the appropriate level of care.

Examples of Candidates for Sub-acute Care

1) Uncomplicated pneumonia without home support system

2) Cellulitis requiring IV antibiotics without home support system

3) Acute enteritis with dehydration

4) Osteoporotic fracture of spine requiring rest and analgesia, with poor home support system

5) Recurrent falls, unsafe to return home, but would benefit from therapy

6) Recent acute care discharge unable to function in the community, but would benefit from therapy

7) Exacerbation COPD requiring pulmonary toilet, 02 sat monitoring, but stable enough for sub-acute setting with reasonable expectation of ability of returning home

8) Extremity fracture which is either unstable or patient has poor home support system and would benefit from therapy to ambulate

9) Urosepis with stable blood pressure

10) Any patient requiring rehabilitation, with a reasonable likelihood of rehabilitation, and ability to cooperate and tolerate a program of rehabilitation, following an acute inpatient stay.

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