FORGING THE PATH FOR MEDICAL RESPITE CARE IN HEALTH SYSTEM REFORM

August 16, 2014Alice Moughamian, RN, CNS, San Francisco Medical Respite Program

Sabrina Edgington, MSSW, National Health Care for the Homeless Council

WHY STANDARDS?

• Improve consistency • Improve quality,

health outcomes, and reduce costs

• Improve opportunities for research

• Improve opportunities for sustainable federal funding

A 2014 study conducted by Duke University found an emergence of “patchwork [medical] respite” processes in the absence of formal medical respite programming.

Source:Biederman, D.J., Gamble, J., Manson, M., Taylor, D. (2014). Assessing the need for a medical respite: perceptions of service providers and homeless persons. Journal of Community Health Nursing, 31(3),145-56.

PROCESS TO DATE

• Under Leadership of Medical Respite Providers Network

• Medical Respite Standards Development Task Force→ Representatives of Nursing, Social Work, Medical, Policy, Legal

and Consumer Viewpoints

• Conducted monthly meetings→ Began Fall 2011

• Focus on the minimum standards

• Alignment with other standards

• Goal to accommodate a diverse range of providers

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STANDARD 1: ACCOMMODATIONSMEDICAL RESPITE PROGRAMS PROVIDE SAFE AND

QUALITY ACCOMMODATIONS

• 24 hour bed• Hygienic

→ Shower facilities→ Laundering facilities→ Clean linens→ Janitorial services

• Accessible and minimal fall risk

• Secured storage

STANDARD 1: ACCOMMODATIONS

• Food (3 meals/day)• 24 hour staff presence

→ Trained in first aid and basic life support→ 24-hour on call medical support at non-congregate facilities

• Safety plans→ Policies and procedures for responding to life-threatening

emergencies (i.e., medical emergencies)→ Patient understanding of fire and evacuation plans→ Code of conduct→ Policy for handling alcohol and illegal or non-medical

prescription drugs → Policy for weapons and staff response to violence

STANDARD 2: ENVIRONMENTAL SERVICESMEDICAL RESPITE PROGRAM PROVIDES QUALITY

ENVIRONMENTAL SERVICES

• Safe handling of biomedical and pharmaceutical waste and other biohazardous materials as needed

• Communicable disease management

• Medication storage• Pest Control

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CONSIDERATIONS FOR COMMUNICABLE DISEASE MANAGEMENT

OTHER CONSIDERATIONS FOR COMMUNICABLE DISEASE MANAGEMENT

• TB• C. diff• Hep A

→ Fecal – oral route→ Implications in food service (i.e., Standard 1)

• Impetigo→ Standard 1 implications

• Shingles

MEDICATION STORAGE

• Licensing→ Administering vs. Dispensing→ Meds need to be stored according to manufacturer

requirements

• Special considerations→ Insulin→ Controlled medications→ Oral chemo agents

• Special precautions→ Outpatient chemo

STANDARD 3: CARE TRANSITIONS TO MEDICAL RESPITEMEDICAL RESPITE PROGRAM MANAGES TIMELY AND SAFE

CARE TRANSITIONS TO MEDICAL RESPITE FROM ACUTE CARE, SPECIALTY CARE, AND/OR COMMUNITY SETTINGS

CARE TRANSITIONS:The movement of patients between health care locations, providers, or different levels of care within the same location as their conditions and care needs change. This may include the transition from the hospital to a primary care provider, home, or nursing facility.

National Transitions of Care Coalition. (2008). Transitions of care measures. Retrieved fromwww.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf

STANDARD 3: CARE TRANSITIONS TO MEDICAL RESPITE

Improving Care Transitions for People Experiencing Homelessnesshttp://www.nhchc.org/wp-content/uploads/2012/12/Policy_Brief_Care_Transitions.pdf

STANDARD 3: CARE TRANSITIONS TO MEDICAL RESPITE

Preadmission→ Working with hospitals to promote medical respite as a

discharge option→ Trainings to promote appropriate referrals→ Timely admission decisions by qualified medical personnel→ Admission decisions based on ability to keep patients safe and

provide the care, treatment, and services needed by the patient

→ Communication with referring agencies when beds are not available or a referral is denied

STANDARD 3: CARE TRANSITIONS TO MEDICAL RESPITE

Admission→ Designated point of contact for referring entities→ Transportation responsibilities from referring entity to medical

respite is outlined in written agreements→ Protocols for transferring patient information→ Medication reconciliation → Reinforcement of discharge instructions→ Patient has and knows his/her accountable provider(s) at all

points of care transition

STANDARD 4: CLINICAL CAREMEDICAL RESPITE PROGRAM ADMINISTERS HIGH

QUALITY POST-ACUTE CLINICAL CARE

• Clinical care provided at the medical respite program

• Ensures an adequate level of care• Requires qualified medical personnel• Patient focused• Interdisciplinary

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QUALITY POST-ACUTE CARE

• Medical records maintained according to local, state, and federal guidelines

• Patients have encounters with clinical staff based on medical need→ RN’s on-site, consult provider as needed→ Provider on-site for referral consultation,

admissions, urgent issues, pain management, medication changes

• q24 hour wellness checks• Providers follow clinical practice guidelines

QUALITY POST-ACUTE CARE

• Interdisciplinary team→ Care and treatment discussed on regular basis with all

members→ All information is shared with team and patient→ Meets regularly to assess plan and progress towards

goals

• Individualized Respite care plan → Patient care is delivered in an interdisciplinary and

patient centered manner.→ Developed in a collaborative manner→ Care plans are assessed, reassessed and altered

accordingly

STANDARD 5: CARE COORDINATION/SUPPORT SERVICESMEDICAL RESPITE PROGRAM ASSISTS IN HEALTH CARE

COORDINATION, AND PROVIDES WRAP AROUND SUPPORT SERVICES.

• Care coordination within the medical respite program and during the medical respite stay

• Medical care coordination• Case Management/Social Services• Coordinate or provide transportation to medical and

social service appointments

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CARE NAVIGATION

• Connection to Community PCP• Connection to Community Specialty Care• Pharmacy reconciliation• Transportation to and from appointments• Connection to community case management

OTHER EXAMPLES

• Respite as an opportunity• Nutrition, rest, recovery• Housing process can begin• Benefits acquisition• Mental Health referrals• Substance use referrals• Medication adherence and teaching

CASE STUDY: MR. H

• 54 y/o male with uncontrolled diabetes, s/p amputation of R 5th toe for osteo and gangrene

• Comes to respite for post op recuperation and follow up.

• Exchanging security services for room/board. Now that he is unable to work, has lost housing.

MR. H: MEDICAL CARE PLAN

Medical Care Coordination•Wound care•Podiatry and Diabetes follow up•Establish PCP•Blood sugar, diet, glucometer teaching

MR. H: SOCIAL SERVICE PLAN

Social Service Care Coordination•Erroneously put on SSDI in 2002. Has since been unable to get ID, job, benefits•Ethics for discharge prior to SSDI being resolved•Discharge Planner (MSW) worked to get birth cert, fingerprints, hospital records, involved local, state and federal agencies. Pelosi’s aide got meeting with SSA

MR. H: RESULT

• Although engaged in the medical care plan, required follow up surgeries, additional amputation

• While taking care of medical needs, could use time to handle social service needs

• Ended up as our second longest length of stay ever (234 days)

• Just moved to permanent supportive housing on Tuesday

STANDARD 6: CARE TRANSITIONS FROM MEDICAL RESPITEMEDICAL RESPITE PROGRAM FACILITATES SAFE AND

APPROPRIATE CARE TRANSITIONS FROM MEDICAL RESPITE TO THE COMMUNITY.

• Discharge planning→ Begins early→ Discharge policy & procedure, including who makes discharge

decisions→ Pt receives at least 24 hours notice prior to discharge from

medical respite (exceptions for administrative discharge)

• Discharge summary to the patient and community providers assuming patient care

• Patient provided with options for placement after discharge

STANDARD 7: MEDICAL RESPITE CARE IS DRIVEN BY QUALITY IMPROVEMENT

• Requires competent staff• Systematic and continuous actions that lead to

measurable improvement in Respite outcomes

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STAFFING REQUIREMENTS

• Core competencies for staff → Includes volunteers

• Job descriptions and annual performance appraisals

• Medical director required• Appropriate training, certification and licensing

is maintained• Staffing based on program’s ability to provide

clinical care and clinical complexity and acuity.• Incident reporting

DATA MEASUREMENT

• Established and secure data collection process→ Program specific performance priorities for data collected and

frequency

• Plan to identify and respond to trends, outcomes, patient experience and performance measures.

• Ability to conduct self audits

DPH MEDICAL RESPITE Episode Form

CITY AND COUNTY OF SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH LCR MED REC #

CAUTION: Federal and State laws protecting confidential patient information apply to patient information contained in this completed form.

MEDICAL RESPITE CLIENT INFORMATION

LAST NAME

FIRST NAME M.I.

ALIASES SSN

DOB

AD

MIT

D

AT

E MONTH DAY YEAR REFERRED BY WHICH HOSPITAL (choose one)

SFGH St. Francis CPMC Davies CPMC Pacific CPMC California St. Luke’s

UCSF Kaiser VA Hosp St. Mary’s Other Hosp (specify):

ETHNICITY (choose all that apply)

CL

IEN

T I

NF

O

Caucasian African American Latino/a Filipino/a

Other:

Asian American Indian /

Alaskan Native Native Hawaiian or Other Pacific Islander

PRIMARY LANGUAGE

English Spanish Other:

GENDER

Male Female MTF Transgender FTM Transgender Other Declined to Answer

ORIENTATION/PREFERENCE

Heterosexual Gay Lesbian Bisexual Unsure Other Declined to Answer

AD

MIT

LIV

ING

S

ITU

AT

ION

CURRENT LIVING SITUATION

Choose one: Select situation that applied

prior to client’s hospitalization.

Homeless: Shelter, no CM Shelter, with CM Outdoors Encampment Abandoned Bldg Vehicle Other

Homeless Transitional: SRO Temporary Jail/Prison LTC or Residential Treatment Temp situation w family/friends Foster Care SRO living with child(ren)

Permanently Housed: (with tenancy rights): SRO Non-Supported SRO Supported Board and Care Apartment House

LAST TIME CLIENT WAS PERMANENTLY HOUSED: MONTH: ___________ YEAR: ___________

REFERRING PRIMARY DIAGNOSIS AT ADMISSION: (choose only ONE option from MEDICAL HISTORY below and write here)

AD

MIT

PU

RP

OS

E

REFERRING PRIMARY PURPOSE(S) FOR ADMISSION (choose all that apply):

ARV Initiation Wound Care PO Antibiotics IV Antibiotics Med Mgmnt Reconditioning/Rehab

CM Anticoagulation Med Teaching Chemo/XRT Awaiting Medical Procedure Assisting with Follow-up

Other (specify):

REFERRAL MEDICAL HISTORY REFERRAL MH HISTORY REFERRAL SA HISTORY

Unable / Refused to Answer

Denies History Ambulatory Disability Anemia Assault Asthma Autoimmune Disease CAD Cancer Cardiac Arrhythmia CHF Chronic Pain Cirrhosis Cognitive Disorder NOS COPD Dental Condition Derm Condition Diabetes Endocrine GI Disease Other (specify):

GYN Disease Hepatitis C HIV/AIDS Hypertension Neuro disease Open wounds,

skin and soft tissue infection

Ortho Condition Osteomyelitis Pneumonia Post-Op Care Renal Disease Seizure disorder TBI Thromboembolic

Disease Urologic

Condition UTI Vision Disability

Unable / Refused to Answer Denies History None Adjustment Disorders Substance Related Diagnoses Anxiety Disorders Delirium, Dementia, and

Amnesic and Other Cognitive Disorders

Disassociative Disorders Factitious Disorders Impulse Control Disorders Not

Elsewhere Classified Mood Disorders Personality Disorders Schizophrenia and Other

Psychotic Disorders Sexual and Gender Identity

Disorder Sleep Disorders Somatoform Disorders Other Conditions (specify):

Unable / Refused to Answer Denies History None Alcohol Barbiturates and other sedatives /

hypnotics Benzodiazepines and other

tranquilizers Cocaine / Crack Cocaine Ecstasy & other club drugs Hallucinogens / PCP Heroin Inhalants Marijuana / Hashish Methamphetamine and other

amphetamines Nicotine Other Opiate * Over-the-counter * Unknown drug(s) * * Specify:

IDENTIFIED DURING STAY: IDENTIFIED DURING STAY: IDENTIFIED DURING STAY:

DPH MEDICAL RESPITE Episode Form, PAGE 2

LAST NAME FIRST NAME

ADVERSE EVENT DATE: TIME

BRIEF DESCRIPTION OF ADVERSE EVENT

MEDICAL RESPITE LINKAGES

PC Provider: __________________________________________________ Already Active Reconnect New Connect Offered/Refused

Diagnostics: ___________________________________________ N/A Already Active Reconnect New Connect Offered/Refused

Pharmacy: _______________________________________ N/A Already Active Reconnect New Connect Offered/Refused

ICM Team: _______________________________________ N/A Already Active Reconnect New Connect Offered/Refused

Community Nursing Care: ___________________________ N/A Already Active Reconnect New Connect Offered/Refused

MH Tx: __________________________________________ N/A Already Active Reconnect New Connect Offered/Refused

SA Tx: __________________________________________ N/A Already Active Reconnect New Connect Offered/Refused

Specialist: _____________________________________________ N/A Already Active Reconnect New Connect Offered/Refused

Specialist: _____________________________________________ N/A Already Active Reconnect New Connect Offered/Refused

Other: __________________________________________ N/A Already Active Reconnect New Connect Offered/Refused

Housing: _______________________________________________ Already Active Applied Offered/Refused

ID: CA ID / SS# Card / Other : _____________________________ Already Active Applied Offered/Refused

Income Benefit: CAAP / SSI / SSDI / VA / Other: Already Active Applied, Award Date:_______________________ Offered/Refused

Medical Coverage Benefit: Medi-Cal / Medicare / VA: Already Active Applied, Award Date: __________________ Offered/Refused

DC

LIV

ING

S

ITU

AT

ION

DID STAY RESULT IN CHANGE OF LIVING SITUATION?

NO If YES check new

situation: COMMENT:

Homeless: Shelter, no CM Shelter, with CM Outdoors Encampment Abandoned Bldg Vehicle Other

Homeless Transitional: SRO Temporary Jail/Prison LTC or Residential Treatment Temp situation w family/friends Foster Care SRO living with child(ren)

Permanently Housed: (with tenancy rights): SRO Non-Supported SRO Supported Board and Care Apartment House

DISCHARGE DISPOSITION MEDICAL TREATMENT PLAN COMPLETED BEFORE DISCHARGE?

MONTH DAY YEAR YES NO, COMMENT:

Discharged to: (review options 1 through 15, select only one)

1. * Psychiatric Emergency Program/Facility: PES Westside Crisis Dore Urgent Care Clinic 5150? Yes No

2. * Medical Emergency Department:

SFGH St. Francis CPMC Davies CPMC Pacific CPMC California St. Luke’s

UCSF Kaiser VA Hosp St. Mary’s Other Hospital: ________________________________________

3. Medical Detox Program

4. Social Detox Program

5. Residential Treatment Program: ____________________

6. Hospice: ______________________________________

7. Long Term Care: ________________________________

8. Completed program and discharged to self-care Address/hotel/room#, if known:

_________________________________________________

9. AWOL

10. * Escorted out due to violent behavior or threat of

11. * Discharged due to inappropriate behavior

12. * AMA

13. * Discharged to Police Custody 14. * Death

15. Other as follows: ______________________________ (* Requires Adverse Event section to be completed)

415-255-3706 – Form Revised 051309 ENTERED INTO CCMS: DATE: _____________________BY: _______________________

NEXT STEPS

• Anticipated public comment period: 9/1/14-9/30/14

• Revisions based on public comment/Task Force discussion

• Testing at volunteer sites• Revisions based on testing• Final standards issued

NEXT STEPS

• Used for training and technical assistance • Opportunities for accreditation/certification• Opportunities for research related to health

outcomes/quality of care/costs• Engage in discussions at federal level to promote

sustainable funding

Q & A

Alice Moughamian, RN, CNS, Nurse ManagerSan Francisco Medical Respite Program

Alice.Moughamian@sfdph.org

Sabrina Edgington, MSSW, Director of Special ProjectsNational Health Care for the Homeless Council

sedgington@nhchc.org