Archive for the ‘Long Term Care’ Category

5 Barriers to Optimal Care in the Post-Acute Setting

January 22nd, 2014 by Jessica Fornarotto

Summa Health System’s care coordination network of skilled nursing facilities (SNFs) is working to decrease fragmentation, length of stay and unnecessary readmissions while improving outcomes of care. Mike Demagall, administrator of Bath Manor & Windsong Care Center, a participant in this network, identified five barriers to patient care that originated in the acute care setting.

First, we found a lack of quality information received upon transfer from an acute care to a nursing facility and the lag time in identification of post-acute bed availability. The social worker was calling or faxing information to a facility, and the facility took up to 24 hours to respond as to whether a bed was available. That person may have been ready that day; instead it postponed that discharge another day.

We also had barriers to the patient’s acceptance of the need for post-acute care. Social workers and care coordinators at the bedside tell them when it is time for rehabilitation.

The next barrier was family expectations. Does the family feel that they need to go to the nursing home? The hospital staff and the insurers had to spot the appropriate levels of care. One of the concerns we had was, ‘Is this going to send a lot of our patients — our referrals — to home healthcare and decrease our referrals by participating in this?’ That happened to not be the case at all.

There was still a lack of knowledge and respect toward long-term care (LTC). All the discharge planning individuals, which were the case manager nurses and social workers, were able to tour the facility. Each facility had the opportunity to present their services and what they do. That helped with the overall cohesion of the group, and it moved this project forward.

There was also a lack of quality information received from the nursing facilities on the transfer to an emergency department (ED). That was information that we needed to get back, just as we were asking for information as those residents were coming in.

Excerpted from: 7 Patient-Centered Strategies to Generate Value-Based Reimbursement

Infographic: Is Technology the Key to Aging Well?

January 15th, 2014 by Jackie Lyons

Although 73 percent of boomers and Gen X surveyed want to age in their own home, they believe the aid of technology will present significant barriers to achieving this, according to a new infographic from Philips and the Global Social Enterprise Initiative (GSEI) at Georgetown University’s McDonough School of Business.

In fact, 95 percent believe technology needs to be better developed to help them successfully age at home or in place. This infographic also details what ‘aging well’ entails, technology comfort levels by generation, healthcare technology security concerns, and much more.

Is Technology the Key to Aging Well?

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You may also be interested in this related resource: 2013 Healthcare Benchmarks: Telehealth & Telemedicine.

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Infographic: Informal Care Givers – $234 Billion Job Goes Unpaid

December 19th, 2013 by Jackie Lyons

Nearly nine in 10 Americans who need some form of long-term care (LTC) get assistance from family members or friends who volunteer their time. An estimate of this work adds up to $234 billion, according to a new infographic from PBS.

This infographic also shows how this compares to the GDP and total U.S. LTC costs, and reasons why these costs will continue to grow.

$234 Billion Job Goes Unpaid

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You may also be interested in this related resource: Implementing Culture Change in Long-Term Care: Benchmarks and Strategies for Management and Practice.

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Care vs. Case Management: 7 Structural Differences

December 12th, 2013 by Cheryl Miller

While there’s no law defining the differences between care and case managers, there are seven structural differences, says Jullie Gray, MSW, LICSW, CMC, principal of Aging Wisdom, and president of the National Association of Professional Geriatric Care Managers, NAPGCM.

Despite the differences, geriatric care and case managers ultimately face the same issues: an aging population, a dwindling supply of geriatricians, and caregivers that need help caring for their ailing family members, while at the same time honoring their “autonomy and safety,” Gray says.

Following is her assessment, based on reviews of NAPGCM’s standards of practice compared to the Case Management Society of American’s (CMSA)’s standards of practice, and various national and regional group member meetings.

To find a care manager, go to National Association of Professional Geriatric Care Managers To read an interview with Gray, click here.

Care Management

Case Management

Background of professional

Diverse – Social work, nursing, psychology, gerontology, other health related fields

Social workers and nurses primarily (with some mental health counselors)


Primarily private for profit (some nonprofits)

Agency/organization: insurance company, hospital, community mental health, etc.

Government: Medicaid program, housing authority, adult/children’s protective services, veterans’ programs, etc.


Client defines the scope of work (based on a care plan that is developed with the client’s input)

Agency defines the limits/scope of work. Typically will be managing a specific disease, issue, condition or event, and focus may be constrained by regulations, policies and funders


Holistic, client/family centered approach

Understanding underlying client/family dynamics

Advocating for client needs & the client’s maximum benefits (i.e., from an insurer)

Client/patient centered but also considers medical/legal/financial issues that can involve stakeholders

Eliminating  non-compliance and over-utilization



Can be a funding source (i.e., insurance company, entitlement, hospital, etc.)


Client pays cost (occasionally some reimbursement from long-term care insurance but this is not typical)

Agency specific funding (hospital system, insurance company, government program, for example)


Promote better quality of life, maintain independence to the extent possible, improve communication among those involved in client’s care, ensure client’s needs are met and client’s goals are achieved, provide education to client and family members

Improve health status, cost effective outcomes and efficiencies, reduce overutilization of services

New, FREE Case Management Trends Download

For additional data on care and case management trends, download the FREE executive summary: More Care Team Integration; Face-to-Face CM Encounters Edge Out Telephonic

With each year, a larger swath of the healthcare industry comes to rely upon the skills of healthcare case managers to influence clinical, quality and financial outcomes. According to the 2017 Case Management Survey by the Healthcare Intelligence Network, the percentage of healthcare organizations enlisting case managers in care management rose from 88 percent in 2013 to 94 percent in 2017. Further, patients are much more likely to encounter a case manager in a provider’s office this year than they might have been four years ago. Two-thirds of 2017 respondents embed or colocate case managers alongside care teams today, versus 54 percent in 2013.

Download this HINtelligence report today for more data on the top clinical targets of healthcare case managers; the top means of identifying and stratifying individuals for case management; and the most common locations of embedded or colocated case managers.

Infographic: Giving Thanks for Caregivers

November 28th, 2013 by Jackie Lyons

As the baby boomer population continues to age, the need for long-term care continues to increase.

Sixty-five million family caregivers in the United States provide care for chronically ill, disabled, or aged family or friends, according to a new infographic from ACSIA, Long Term Care Inc. This infographic presents the duties, effects and financial aspects of care giving, along with statistics and facts regarding caregiver education and health.

Top 15 Enlightening Facts about Caregivers

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You may also be interested in this related resource: Guide to Care Transition Management.

Meet Geriatric Care Manager Trish Colucci: ‘Jersey Girl’ Finds Passion Helping Others

November 26th, 2013 by Cheryl Miller

This month we provide an inside look at a healthcare case manager, the choices she made on the road to success and the challenges ahead.

Trish Colucci, RN, Certified Geriatric Care Manager, Certified Gerontological Nurse, Certified Case Manager, current president of the New Jersey chapter of NAPGCM, Owner of Peace of Mind Care Management Services, LLC

HIN: Tell us a little about yourself and your credentials.:

(Trish Colucci) I have been a N.J. state Registered Nurse (RN) since 1985 and have additional certifications in gerontological nursing, case management, and life care planning. Currently, I am the president of the N.J. chapter of the National Association of Professional Geriatric Care Managers (NAPGCM). Prior to that I served two years as treasurer and two years as vice president.

What was your first job out of college and how did you get into case management?

When I graduated, I started working as a floor nurse at a local hospital. Although I always saw myself in pediatrics, there were no positions available at the time, so instead I accepted a position on the orthopedic floor. It was serendipitous! In that unit, I developed a love for working with elderly folks. I was later offered a shift in career to insurance case management, at the time when that field of nursing was brand new. In that position, I developed valuable organizational skills and clinical knowledge that helped me coordinate care for our catastrophically ill or injured claimants and to ensure that they received the best medical care possible.

Has there been a defining moment in your career? Perhaps when you knew you were on the right road?

Years later, I gave birth to my son who has Down Syndrome, and who had a lot of special medical needs. I was able to utilize my case management skills (which were now second nature) to coordinate a team of top-notch doctors who addressed Michael’s multitude of medical problems and worked together, with my management. It was after that that I noticed friends coming to me to ask advice for coordinating care for their own loved ones. It helped me realize how valuable my case management skills were and how they could be helpful to others trying to navigate the confusing worlds of medical care and insurance.

In brief, describe your organization.

Peace of Mind Care Management Services, LLC is a care management firm that assists families, guardians and caregivers with the management of their loved one’s personal and medical care. We specialize in crisis management, often finding families confused and overwhelmed by their responsibilities in an arena with which they are not familiar. As care managers, we assess the situation and create a specialized plan of care that addresses the needs of the client within the available budget. We offer support, resources and guidance so that families feel more comfortable and informed in making important decisions for the care of their loved one.

Serving as president of the New Jersey chapter of the NAPGCM has opened my eyes to opportunities for care managers on both the local and national levels. Although the field of geriatric care management has been around for over 25 years, it is not well known by the general public. Our chapter’s main focus over the past year has been on developing a solid, working public relations committee, and to make, “geriatric care management” a household word and the first point of contact for families who need help with their loved one.

What are two important concepts or rules that you follow in care management?

  • The most important concept in care management is a trusting relationship. Our clients need to know that as care managers we provide honest, caring advice that is in their (or their loved one’s) best interests. We are not financially connected to any resource we may offer to a family, and this keeps our advice objective and trustworthy. We refer to resources we would use for our own family members and this provides an extra level of trust with our clients.
  • Compassion is another important concept. At Peace of Mind, each client is as precious as the next, coming to us with his or her own history and special needs. We reach out to our clients and their caregivers with compassion and empathy, developing an understanding about where they’re coming from so we can tailor our guidance in a way that makes them the most comfortable.

What is the most satisfying thing about being a care manager?

What I derive the most satisfaction from is the look on the face of a client or caregiver we’ve helped. Seeing on their faces the signs of relief…of tensions easing…because they got the help they needed to care for their loved one, provides me, as the care manager, the signs that I’ve done a good job for the family. Even in situations where clients are in the process of dying, knowing that I have coordinated their care such that they will leave this world feeling comfortable and loved, makes me feel good about the work I do.

What is the greatest challenge of care management and how are you working to overcome the challenge?

What I love about being a geriatric care manager is the diversity of duties, however that’s one of the things that makes this job such a challenge! Each day brings forth some new challenge, and my schedule can change hour-to-hour. It helps to be flexible! I am fortunate to have a strong, warm and wonderful care management team made up of nurses and social workers. When we are faced with tight situations, we reach out to one another for assistance and support. Whether it’s a race against time to get medical equipment in the home before a client comes home from the hospital, or a family member who needs extra hand-holding and reassurance on a particular day, or an unexpected emergency with a client that needs immediate attention, we are ready to act.

Where did you grow up?

I grew up in Denville, N.J. and am the eldest of three girls. I am a “Jersey Girl” through and through. My dad was a police officer and my mom was a bank teller. Sounds like the makings of a good Bruce Springsteen song, doesn’t it?

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HINfographic: 12 Trends on the ACO Frontier in 2014

November 1st, 2013 by Jackie Lyons

The accountable care organization (ACO) movement shows no signs of slowing. In fact, looking ahead, there is a greater number of ACOs in the wings than one year ago.

Forty-four percent of developing ACOs will be helmed by physician-hospital organizations, according to a new infographic from the Healthcare Intelligence Network. This HINfographic examines 12 emerging ACO trends at 138 healthcare organizations and delivers tactics from a top performing Pioneer ACO, Monarch HealthCare.

12 Trends on the ACO Frontier in 2014

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Information presented in this infographic was excerpted from: 2013 Healthcare Benchmarks: Accountable Care Organizations. If you would like to learn more about accountable care organizations, this resource includes sector-specific qualitative data on comparative 2011-to-2013 data on key ACO metrics, metrics on use of case management, patient portals, evidence-based care and many other ACO program components.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

HINfographic: Healthcare Strategic Planning for 2014

October 16th, 2013 by Jackie Lyons

Sustained growth in emerging reimbursement models, including accountable care, bundled payments and shared savings will continue to have an impact on innovation within the healthcare industry in 2014 as providers and payors struggle to find more ways to reduce costs within their systems and better manage the care they provide.

Hospital readmissions dropped by nearly 70,000 in 2012, and this trend is expected to accelerate through 2014, according to a new HINfographic from the Healthcare Intelligence Network. This HINfographic identifies current healthcare industry trends, and provides details on what to expect in 2014.

Healthcare Strategic Planning for 2014

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Information presented in this infographic was excerpted from: Healthcare Trends & Forecasts in 2014: A Strategic Planning Session. If you would like to learn more about healthcare trends and forecasts in 2014, this resource includes a detailed and actionable roadmap to the key issues, challenges and opportunities for healthcare providers and payors in 2014.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

SNF Community Partnership Shores Up Accountable Care

October 1st, 2013 by Jessica Fornarotto

To support ACO construction, industry thought leaders advise hospitals to monitor what goes on across its care continuum and to partner with facilities it discharges its patients to most often to reduce 30-day readmissions. A prime example is the skilled nursing facility (SNF) network coordinated by Summa Health System, discussed here by Carolyn Holder, manager of transitional care for Summa Health System, and Michael Demagall, administrator of Bath Manor & Windsong Care Center.

(Carolyn Holder) We have been working on a pilot model for accountable care. Accountable care is the focus on primary care wellness in population health. Patients and families need to be actively engaged in this process. It coincides with having the right level of care provided to the patient where they need it, and that is what we are talking about with accountable care. You need partnering relationships between hospitals and physicians and through all levels of care to be able to support that individual in their wellness or illness effectively.

What is the value of this care coordination that worked in the accountable care model of care? It relates to the Triple Aims and looking at providing safe, patient-centered, timely care. We are collaborating to do that with our partner facilities. We have been working at improving health and patient populations in communities. Patients in this situation need rehab, so they have had some functional impairments and frailty. We are trying to get them back to their optimal level of function. To do this, we partner with our SNFs to support that level of care and lower the per capita cost of healthcare.

We also work with community-based long-term care. That has certainly not taken away from any of our nursing facilities any patients that are appropriate or keeping them in the optimal function that they would want.

(Mike Demagall) Through this development of the ACO on the skilled nursing side in working with the hospitals, one thing we focused on was the key indicator comparisons for our 2010 data.

Along with the hospital, we will provide standardized numbers of information that we can get back, that we are going to be held accountable for from the SNF side. The hospital knows what we do is safe and efficient, patient-centered and equitable for everybody involved. As we move forward with the ACO through care coordination, we will look at numbers and information that we can share as a community with the health system so they know what the facilities are doing. There are many reasons that is done, but one of the greatest accomplishments is everybody working together.

Out of 39 homes in the county, the collaboration has been incredible. Initially there was some hesitation, but the collaboration has moved forward, and we are not afraid to share that information. The information is blocked and as we provide information back, it will be blocked from other members except for the hospital, who knows who those numbers are. However, from my facility, I may see a readmission rate at one facility lower than ours although we have the same type of case mix index. I need to look at our facility and ask, “What can we do to get better? What are they doing that we aren’t?” Therefore, everybody gets better as a group, and that is ultimately the goal of the community and the health population in the community we serve.

Infographic: A Short Look at Long-term Care for Seniors

September 16th, 2013 by Jackie Lyons

Under the ACA, there are provisions for states to expand Medicaid to help people receive long-term care (LTC) services. Still, as baby boomers age, the need for LTC increases.

Thirty-five percent of U.S. adults 40 years or older say they have set aside money for their long-term needs, according to a new infographic from the Journal of the American Medical Association. This infographic also includes information about the number of seniors who will need LTC, the role of Medicaid as the primary payor for LTC, the shifting of Medicaid spending from institutional-based care toward community-based care and more.

A Short Look at Long-term Care for Seniors

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You may also be interested in this related resource: Formula for CMS Five-Star Quality Population Health Management.