The Geriatric Population : A Significant Impact On Federal Spending Through The Medicare Program

The overall process of discharging a patient from a hospital and the transition back home or to a care facility are critical advancements in the overall course of both acute and long-term care. It is important that the hospitals releasing these patients have ensured the proper overall course of care from beginning to end. The lack of consistency with both the discharge process and the quality of discharge planning has led to many avoidable readmissions. To reduce the amount of hospital readmissions, it is imperative that hospitals recognize the need for focused patient care and that programs are being implemented to assist in the care transition.

Medicare, the federal governments health insurance program, finances acute medical care for nearly all elderly Americans over the age of sixty-five. However, very few long-term care services are covered. Medicare finances long-term care only partially through it’s limited skilled nursing facility (SNF) and home health benefits. “Despite recent growth in spending on these benefits, much of the SNF and home-care paid for by Medicare remains short-term rehabilitative care, often related to a hospital stay or outpatient procedure. Medicare covers SNF care for up to 100 days following a hospital stay of at least three days. For homebound persons needing part-time skilled nursing care or therapy services, Medicare pays for home health care, including personal care services provided by home health aides.” (Feder, Komisar, and Niefeld) All that is not covered, the elderly are expected to cover with savings, private insurance policies, and financial support

Many nursing homes assume in error that if a patient has stopped making progress towards recovery then Medicare coverage should end. In fact, if the patient needs continued skilled care simply to maintain his or her status then the care should be provided and is covered by Medicare.In fact, patients often receive an array of treatments that don 't need to be carried out by a skilled nurse but that may, in combination, require skilled supervision.Even in cases where the SNF initially treats the patient as a Medicare recipient, after two or more weeks, often, the SNF will determine that the patient no longer needs a skilled level of care and will

In searching information regarding the rehospitalization rates and the drop of Medicare reimbursements for those stays, I was surprised to have found there was so much information regarding this and the tools that are out there also to use. My direct supervisor, Amy Suydam RN CPS, was also helpful in bringing up some things not thought of that would assist in the success of our organization in achieving our goal of decreasing rehospitalizations by 10% within the next 6 months. Amy Suydam RN CPS did not feel this was an unreasonable timeframe and decline to be looking towards. This is something we have discussed many times as our organization is non-for profit and this is very important that we follow through with our teachings and get all the information put out there that we can regarding these changes.

Readmission to a hospital creates strain and added expense for the patient and hospital; in 2011, hospital costs due to readmission were almost $41.3 billion (Hines, Barrett, Jiang, & Steiner, 2014; Rau, 2014). There are many aspects of healthcare associated with readmission, such as lack of discharge planning and education, which need to be addressed i to decrease the amount of preventable re-hospitalizations.

More people are living much longer lives than in years past. People are very surprised to be living much longer lives than they thought they would. Health care has played a large part in patient longevity. There are many normal changes that come along with aging, however, because people are living longer these normal changes can become chronic problems. Common aging problems that can make the older adult a vulnerable population are reviewed in Gerontological Nursing (Tabloski, 2014) and can include nutritional needs, medication management, sleep changes, oral or mouth care, renal problems and musculoskeletal concerns. According to A Profile of Older Americans: 2013 (http://www.hhs.gov), there are a large amount

This model reimburses hospitals based on quality of care instead of the volume of patients. The quality of care is assessed by patient questionnaires and if hospitals are unsatisfactory penalties may be imposed (Edwoldt, 2012). The value-based system also affects Medicare and Medicaid. It was reported that Medicare readmissions within 30 days of discharge cost 17 billion dollars annually (Edwoldt, 2012). Due to the high costs of readmissions Medicare and Medicaid have implemented a Hospital Readmission Reduction program. A formula is utilized to evaluate readmission rates within 30 days of discharge for any medical reason related to their original admission such as heart failure and pneumonia. Upon review the hospital is potentially penalized. It is important that nurses strive to provide excellence in care despite their beliefs on the ACA. Nurses have the ability to provide a safe patient environment and reduce the risk of hospital associated infections by following hospital protocols such as hand washing.

Since the original plan for SNF stay was 21 days, which is the total number of the days paid by Medicare Part A 100%, there was going to be no out of pocket pay from the patient’s side if there would have not been a UTI acquired. Objective findings show that the UTI was due to poorly performed evidence-based protocol process in the urinary catheter maintenance and fitting. This cost the patient to start paying money ($144.50/day x 14 days as explained before) out of her pocket for cause that was not inevitable. Not only did the patient have to suffer being weak, having and infection and missing on her rehabilitation program, but she had to also pay for each extra day that she had to stay there for a fault that was not hers. It is clearly not only a failure of the SNF’s operational system, quality of care and healthcare professionals’ performance, but also of the governmental support which directly penalizes the patient for

In addition, it also measures the quality of care and patient satisfaction. In 2015, the US Secretary of HHS has announced a goal of 85 percentages of Medicare Fee for Service payments tied to quality or value. In addition, many new payment models are associated with HRRP; for instance, forthcoming Skilled Nursing Facility VBP program and Dialysis Adequacy measure , potentially specifies preventable readmission measures. As the system is moving from quantity to quality, it is beneficial to implement quality of standards to optimize future benefits for the community and Central Health as well. Currently, Central Health has higher readmission rate than national average with an overall rating of 2 out of 5. Penalties incurred due to below standard of care could strain hospital resources to utilize for the betterment of our facility. Furthermore, the incentive structure has concerned Central Health to reevaluate the mode of practice and care provided engaging healthcare providers and patients. Central Health is committed to reducing readmission rates by identifying and sharing best practices for long term benefits. Given the flexibility of penalty under the 21st Cure Act, the initial program will focus on readmission prevention within 30 days of hospital

Hospitals nationwide have been striving to reduce the rate of patient readmissions. Both the federal government and private insurers are tired of picking up the tab. In a 2009 study in the New England Journal of Medicine, researchers estimated that a year's worth of unplanned re-hospitalizations cost Medicare alone $17.4 billion. Congestive heart failure is a particularly big target, as one in four patients end up back in the hospital within 30 days of discharge. Starting in the fall of 2012, the government will cut Medicare reimbursements for hospitals with higher-than-expected 30-day readmission rates for heart failure and two other conditions: heart attack and pneumonia (Avril, 2011).

There is a problem of avoidable hospital readmission rates for the Medicare and Medicaid populations that lead to adverse consequences not only for the patient, but also the payer and hospital. In order to decrease these avoidable readmission rates it is important to identify processes that can be implemented at the health plan level such as pre-discharge hospital visits by health plan staff, and post-discharge care coordination.

The average per day fee in 2010 was $219.00. Compiling a fee schedule from a few facilities in my immediate area I was able to determine that this fee has increased since 2010 with the average daily fee being $266.00 There is 100 day cap on the any one stay after which Medicare will no longer pay and the patient will become financially responsible. By the year 2030 “The population aged 65 and older is predicted to double from around 38 million to 71 million, according to estimates by the U.S Census Bureau.”(Bezaitis, 2009) This resonates volumes today as it touches on the prediction of shortages in the workforce of SNFs if Medicare budgets were to be cut; predicting that the shortages would be viable on all levels of long-term care. “About 5.7 million to 6.5 million long-term care workers such as nurses, nurses’ aides and home health and personal care workers, will be needed by 2050.” (Bezaitis, 2009) The pending cuts will without a doubt create a domino effect throughout the long-term care industry; a drastic cut in funding creates a need to adjust operating budgets thus affecting employment

Veteris Health, LLC is a healthcare company specializing in the care of elderly Medicare patients. Although its headquarters is located in Cleveland, Ohio, it serves elderly people across the nation. Veteris Health contracts with Medicare health insurance providers and provider networks across the United States to provide extensive in-home health assessments of the Medicare insurance providers’ clients at no cost to the patient. The assessment consists of everything from seeing how the person is living in their domicile, to what prescription drugs they are taking, and a comprehensive physical exam. This is to provide innovative healthcare solutions to improve health and quality of life of the elderly.

Whilst searching for literature, it shown that some elderly patients specific needs were not being met. The World Health Organisation (WHO) believe that it is important for health professionals to take a holistic approach towards the elderly patients, to see explore any other possible factors that will influence the reduction of their quality of life. (WHO, 2011).

For years, healthcare costs have continued to increase in the United States and policymakers are constantly trying to find ways to reduce spending. According to reports, in 2011, about $900 billion out of the $2.6 trillion annual health care spending was wasteful spending. In the following year, there was a reported $690 billion wasted annually on healthcare. This wasteful spending is attributed to ineffective health care delivery, cost of adverse events, and poor care coordination that has led to avoidable readmissions (Lallemand, 2012). In the United States, readmissions are the highest amongst patients with chronic diseases accounting for about 90% of avoidable readmissions in 30 days after discharge, and costing the industry an estimated $17 billion. These readmissions are a result of inadequate discharge planning, lack of follow-up, and lack of education on disease management (Jayakody et al., 2016). Policymakers on the federal and state level have developed and implemented several programs, some varying state to state, to help reduce wasteful spending while improving quality of care.