Posted on March 19, 2021 by Elder Care Consultants, Inc.

At discharge, the patient is transported to the rehabilitation facility, typically by ambulance or wheelchair van unless the patient is being transferred from the hospital to their Inpatient Acute Rehabilitation. The staff must quickly begin the task of getting to know its new patient which may be simplified if the transfer is in-house.

When the patient arrives, nursing staff will have reviewed the patient’s current hospital records, but typically knows little about his/her other medical or social history. Once the patient has arrived, his/her medications are ordered according to the records sent from the hospital, some of which may have been changed during the hospitalization. Nursing staff will physically examine the patient and test the patient’s mental acuity. Both the physical and mental status exam can be stressful for the patient. The initial mental status exam may not reflect the resident’s true mental acuity, but rather reflect a reaction to the multiple transfers (home or residential facility, to hospital, to rehab).

Within 24 hours, the patient and records will also be examined by the staff physician or the physician’s nurse practitioner who can make medical and rehab recommendations. The rehab staff (PT, OT, ST) and dietician will also meet the patient to begin forming the initial treatment plan.

Patients may be confused by his/her new surroundings, staff, and routines. Staff will be wearing masks and other protective clothing, which can be further disorienting to the patient.

The task of getting to know the patient, particularly important medical history may be complicated by COVID precautions.  Some patients may be unable to provide much information about his/her medical history, medication regimen, or even dietary preferences.

Sub-Acute Rehabilitation and Acute Inpatient Rehabilitation staff work hard to provide care to patients who are COVID positive or are ill with COVID-19 and to keep the rest of the residents and staff safe. There are significant differences in how facilities manage this care. Some facilities will not accept COVID positive patients while others segregate them from the rest of the residents. Providing quality care and rehabilitation to all residents has become a challenge.

The impact of the lack of contact with the familiar faces and voices of loved ones cannot be underestimated. Residents feel lonely, confused, and sometimes depressed. These emotional states can negatively impact rehabilitation, appetite, and ultimately the patient’s recovery.

How are we helping patients and families? It is important for rehab staff to gain as accurate a picture of the patient as possible. By coordinating with families and the community physicians even prior to transfer to the rehab, we are able to work closely with nursing, rehab, and social work staff and their assistants to help them get to know the patient more fully and accurately from early in the rehab stay. How well was the patient functioning prior to the hospitalization? Where was he/she living and where would he/she likely live at the end of the rehab stay.

We can be in the best position to advocate for the most optimal rehab goals and outcome. When appropriate, we can advocate for more rehab sessions or more frequent treatment plan reviews. We also work with families and residents to bridge the physical distance by using various technologies to communicate and see one another, helping to mitigate the impact of the separation. We then work with patients and families as they look forward to the day rehab at the facility ends and a plan for future care is put into place.

Be sure to read Part I on In-Patient Acute Rehabilitation vs. Sub-Acute Rehabilitation and Part II on Hospital Discharge Process to Inpatient Acute Rehabilitation or Sub-Acute Rehabilitation.

Posted on March 12, 2021 by Elder Care Consultants, Inc.

Post Hospital Rehabilitation

Following a hospital stay for a planned surgery, an injury or illness, many patients benefit from skilled rehabilitation at a facility after discharge. There are two types of facilities: (1) Inpatient Acute Rehabilitation Facility (IRF); and (2) Sub-Acute Rehabilitation Facility (SNF). Note: SNF refers more generally to a Skilled Nursing Facility, which many people know as a “Long-term Care / Nursing Home.” Many Sub-Acute rehab rooms are located within a SNF.

Both facilities provide physical therapy (PT), occupational therapy (OT), speech therapy (ST), therapeutic recreation (RT), and nursing. Below are some differences.

Intensity:

• IRF patients must be able to participate in two three-hour intensive therapy sessions, five to six days a week. Typically, the goal is to return patients to the community quickly with an average stay of 12-15 days.
• IRF treatment teams maintain a vigorous approach toward functional improvement and update the patient’s treatment plan weekly.
• SNF patients may receive therapy from four to six days a week, but for shorter sessions than at an IRF, one to two hours per day. The average length of stay is 26.4 days. The goal may be to return home, to an independent or assisted living facility, or to a long-term care facility.
• SNF treatment teams update their treatment plan at least every 30 days while the patient is receiving skilled (rehab) care.

Staffing:

• IRF’s must have a board-certified rehabilitation physician and a physiatrist on staff. The physician must see the patient at least three times a week and often has an office on-site.
• IRF’s often have Certified Rehabilitation Registered Nurses (CRRN).
• SNF physicians must see the patient every 30 days while the patient is receiving skilled care and their office is typically located off-site.

Payment:

Medicare Part A (or other insurance policies) covers the cost of both IRF and SNF skilled care so long as the patient continues to meet the insurance guidelines (www.medicare.gov).

• IRF costs are covered fully for a maximum of 60 days. If the stay exceeds 60 days, the patient is charged a co-pay for days 61-90 or may use their Medicare Lifetime Reserve Days.
• SNF rehab stays are covered for days 1-20. Days 21-100 have a co-pay which may be covered (all or part) by the patient’s supplemental plan. Medicare advantage plans may be different.

Who decides which type of facility is best? If the patient meets Medicare’s rehabilitation benefit guidelines for care at a facility, the decision about which kind of facility is made by the hospital treatment team in coordination with the receiving facility. However, the patient, family, or care manager can offer important input:

• If the patient’s endurance was good prior to hospitalization it may be appropriate to advocate for a trial stay at an IRF, even if the patient may not be able to return home, but perhaps instead to an assisted living facility.
• If there is no IRF nearby, the family may decide that rehabilitation at a SNF should be considered. While at the SNF, family members or a care manager can advocate for more therapy and more frequent treatment plan reviews.
• If a patient’s level of functioning is low, then a SNF may initially be more appropriate. If the patient makes significant gains while at the SNF, then a referral and possible transfer to an IRF for more intensive therapy can be considered.

Posted on December 11, 2020 by Elder Care Consultants, Inc.

During Thanksgiving 2020 we wanted to be with family and friends but the cautions from medical professionals made decisions about what we should do difficult. We were confused, sad, angry, isolated. In addition, some of us are grieving losses.  Now Christmas, Hanukkah, Kwanzaa are upon us, and we face the same challenging decisions.

We still want to find ways to be joyful, thankful, and compassionate. We need connection.

How do we manage the holidays? We can start by determining what is meaningful about the holiday for each of us. We need to shape our behavior accordingly, even if it differs from past holidays.

For example, whether or not there are financial constraints, this may be the year to send cards, homemade items, or other personal gifts. That may touch on the important aspects of the holiday and even move us away from a more frenzied atmosphere of past holidays.

Important decisions need to be made about whether or not to gather together and, if so, with whom. It is important to remember that not all in your family/friend circle will manage their emotions and the restrictions in the same way.

The clearer we are about our own limitations and needs and the more we can be empathic about how others are coping, the more we can listen to one another to find common ground.

When making holiday plans, it’s important to try to reach consensus around how you will each behave during the pandemic, both through the holidays and in the months beyond until it is safe to lift the restrictions. We can assess our own risk factors and those of the others in our circle. We can each identify the ways we will keep ourselves and our loved ones safe, and where we feel able to compromise with others and where, not.

The separation from elderly loved ones, whether they’re living in their own homes or in a senior residential setting creates even greater challenges. You want the holiday to be meaningful and it is natural to want to arrange in-person visits. But can you? You want them to be safe and you have to consider the safety of those with whom you live.

The senior consultants at Elder Care Consultants (ECC) are problem solvers, before COVID-19 and especially now. We can help families gather the information they need to make decisions, and we can help manage the decisions they make.

Here are a few of the ways we have been helping families.

• Assessment and planning for in-person visits. Determining whether to visit requires a careful assessment. We have been working with families to create a checklist and protocols which assess medical safety, physical or cognitive limitations, emotional well-being, mental health histories and current status. If an in-person family visit is manageable, we can help maximize safety and connection by carefully preparing for the visit with the appropriate PPE equipment and by reviewing symptoms and precautions.
• Care Manager intervention/visits. If in-person family visits are not possible there are several ways our care managers can help:
  • With precautions, we can visit your loved ones during the holidays. In-person care manager visits can provide with companionship, activity, reassurance and monitoring of well-being. Perhaps they need help sending cards or maybe you would like a special tasty holiday treat delivered.
  • We can help arrange for electronic connections. Often, seniors have difficulty managing electronic devices and apps. We can facilitate their use. We have, for example, set up successful connections through FaceTime, Grandad, Amazon Echo, and Care Hub. We can help your loved-one watch home videos of your family.
  • Often, after an in-person visit by family members or a care manager, it becomes apparent that increased professional assessment or oversight is warranted. Perhaps more help is needed or a move to a more supportive environment needs to be considered. We can work through the options with you and help to implement them.

• Even under ordinary circumstances most people agree that as enjoyable as the holidays can be, the level of stress increases. ECC care managers are attuned to the stresses throughout the family and our consultations take into consideration not only the well-being of the senior member, but all those who care for them.

Too much stress can result in “caregiver burnout.” Refer to our our article on caregiver burnout.

Every family is unique We help create a plan to celebrate and to mitigate isolation and loneliness that fits your situation. We respect and celebrate the families and caregivers who are doing your best to create a meaningful holiday season.

We can dedicate ourselves to staying safe in 2020 so we can gather for the Holidays in 2021!

‘It makes no sense’: Feds consider relaxing infection control in US nursing. The federal government is considering rolling back infection control requirements in U.S. nursing homes – even as the long-term-care industry’s residents and workers are overwhelmed by the coronavirus. Read more.