Posts Tagged ‘Long Term Care’

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: 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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Healthcare Business Week in Review: Hospital Surgery Ratings, Long-Term Care Costs, Medicare Drug Plans

August 9th, 2013 by Cheryl Miller


Location, location, location.

While it definitely impacts the price of real estate, it doesn’t necessarily influence a hospital’s surgery rating, according to Consumer Reports’ first ratings survey on how patients fare during and after surgery.

In fact, some hospitals do a much better job than others, despite their location. The report reflects wide variation, sometimes between hospitals only a few miles apart. For example, the Greater Baltimore Medical Center earned high marks on the overall surgery rating, as well as for several individual procedures, but the Johns Hopkins Bayview Medical Center, also in Baltimore, got a low overall surgery rating.

The report, detailed inside, includes overall surgery ratings, which combines results for 27 categories of scheduled surgeries, as well as individual ratings for five specific procedure types: back surgery, hip replacement, knee replacement, angioplasty and carotid artery surgery. They are important because up to 30 percent of hospital patients suffer infections, heart attacks, strokes, or other complications after surgery, but these records are largely hidden from consumers, Consumer Reports says.

Another area of concern that has largely been hidden from consumers is the high cost of medical errors, according to the Leapfrog Group.

A new tool is available to counter this costly trend — the Hidden Surcharge Calculator tool — which allows purchasers to calculate how much they spend annually on unnecessary costs due to hospital errors that occur within general acute care hospitals.

Reports estimate that purchasers can pay nearly $8,000 per patient in hidden surcharges due to medical errors; for employers with 1,000 hospital admissions per year that cost can near a whopping $8 million in avoidable fees, not to mention harm to patients. Every year, more than 180,000 Medicare beneficiaries die from hospital-acquired infections (HAIs), errors, accidents and injuries.

Purchasers can use the calculator to enter their own claims data and local hospital safety ratings from Leapfrog’s Hospital Safety Score Web site to learn the estimated hidden surcharge they pay annually for hospital errors.

More news on not-so hidden costs of long-term care: they continued to increase across all provider options, according to a study from the John Hancock Life Insurance Company (John Hancock).

Already high, within the last five years, costs for senior living facilities rose anywhere from 2 percent for an assisted living facility ($41,124 annually) to nearly 4 percent for a private nursing home room ($94,170.) Considered to be one of the most significant uninsured financial risks an individual can face, according to John Hancock officials, the company updated its interactive cost of care map and calculator to reflect the latest findings, and make long-term care costs planning easier.

And lastly, some good financial news: Medicare drug premiums remained stable for four straight years in a row, according to the Department of Health and Human Services (HHS). The average premium for a basic prescription drug plan in 2014 was expected to remain stable at an estimated $31 per month. More than 6.6 million people with Medicare have saved over $7 billion on prescription drugs since the ACA was implemented, an average of $1,061 per beneficiary, the HHS said.

Meet Geriatric Case Manager Denise Digh: Providing Patients, Families with Road Maps to Future

May 3rd, 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.

Denise Digh, BA, RN, CCM, Owner/Senior Care Manager at Silver Coordinated Care, PLLC/Silver Concierge Services, LLC

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

(Denise Digh): I have a bachelor’s degree in political science and French, and an associate’s degree in nursing (ADN). I am also a certified case manager. I have been a workers’ compensation case manager for many years, working for the State Fund in Maryland and then in field case management. I started my own company, Silver Coordinated Care, PLLC almost two years ago and practice geriatric care management. This grew out of living with my in-laws and helping my husband be a caregiver to his parents for several years, and also being the only caregiver for my mom who has Alzheimer’s disease.

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

My first job out of nursing school was with the surgical intensive care unit (SICU) and medical step down unit at Johns Hopkins Hospital in Baltimore. I then went into homecare case management for several years. I actually got into field case management when an old regional manager of mine opened her own agency and called me out of the blue to see if I would like a new job. I did and have been doing case management ever since – first in workers’ compensation and now with my own geriatric case management company.

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

I can’t say I have one defining moment. I just always felt completely comfortable in case management and felt like it was definitely the right road for me. It suits my strengths. I have always been very good at organization and time management and have learned I hate being locked in an office all day!

In brief, describe your organization.

I am the owner/operator of a geriatric care management company, Silver Coordinated Care, PLLC and am co-owner of a senior transportation and concierge service, Silver Concierge Services, LLC. I strive to help adult children obtain superior care for their elderly parents (or other loved ones), whether that be finding the right homecare services, durable medical equipment (DME), renovation company, etc. or by helping them find the perfect senior community. I also do patient advocacy work, attending physician appointments to make sure the doctor is clear with what the patient needs, and the patient, and their loved ones, understand the plans put in place. I also offer medication management services.

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

I always try to be comprehensive in my assessments, whether they be for finding a community or just doing medication management. I also pride myself on creating custom care plans for my clients — no cookie-cutter reports! I call my care plans SeniorCare Roadmaps™.

What is the single most successful thing that your organization is doing now?

My most popular services right now seem to be finding the right senior community and doing medication management. In fact, the need to find the correct senior community has become so popular, I’ve created a new Web site for families who just need this service. It will launch in a couple of weeks and is called www.NCSeniorHousingSolutions.com. Watch for it anytime!

Do you see a trend or path that you have to lock onto for 2013?

I think there is a subtle but definite trend of people being more open to looking at family care homes rather than large assisted living communities. These homes are in regular neighborhoods and offer all the important services an assisted living does but in a home-like setting. Most homes have only six or fewer residents.

I also see geriatric care management becoming more important and known as the boomers start being seniors and retiring. I think they definitely are looking for more wellness-like programs and the ability to plan out their retirement funds carefully, especially when considering the need for assisted housing in the future. People used to retire at 62 and only lived to around 68 or70. Many people are retiring much later now and living well into their 80s or 90s. It takes a lot of planning to be successful!

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

I derive the most satisfaction from my clients saying that they didn’t know what they would have done without me. I don’t say that to be conceited but it is a really warm feeling to know that what you did for them is so appreciated and has really changed their lives for the better!

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

In my industry, the biggest challenge is not being able to get insurance companies to pay for the important services of a geriatric case manager. Other than some long term care plans (which many elderly people today do not have) insurance does not pay for case management services. We could save them so much money by making sure care is superior, medications are being taken properly and everyone is in a safe and healthy environment so that hospitalizations could be avoided. It is an uphill battle.

What is the single most effective workflow, process, tool or form case managers are using today?

There are many different case management systems out there. I don’t use a particular one. I find my big calendar and a smart phone with my email are my biggest helpers!

Where did you grow up?

I grew up in Corpus Christi, Texas and moved to North Carolina when I was 19 as my father retired and he was from there. I still consider myself a Texan even though I now live in Virginia.

What college did you attend? Is there a moment from that time that stands out?

I first graduated from Guilford College in Greensboro, N.C. with a double major in political science and French. Needing an actual job, I returned to school and received my ADN from Surry Community College in Dobson, N.C. The biggest event that sticks out from my college days is the semester I spent in Paris and traveling around Europe. It was a really enlightening time and made me truly appreciate how lucky we are to live in the United States!

Are you married? Do you have children?

I am married to a wonderful husband who can fix anything and supports me in my crazy endeavors. I also have two gorgeous children – my daughter, Taylor who is almost 15 and my son Bear (Barrett) who is just about to turn six.

What is your favorite hobby and how did it develop in your life?

As busy as I am, regular hobbies are difficult but I love to read and do so every night. My family were all big readers and we always had a love of books. I also really enjoy cross stitching, which I don’t have the time to do much any more, and baking. I had a small cake decorating business for a while and it was a great creative outlet. I also wrangle a bunch of chickens and four dogs!

Is there a book you recently read or movie you saw that you would recommend?

I recently read Agenda 21 (by Glenn Beck) which was a very scary view of future possibilities if we don’t start standing up for our Constitution. I’m currently reading House Girl (by Tara Conklin), which is about a modern day legal reparations case, as well as the life of a slave in Virginia in the 1800s.

Any additional comments?

I hope that case management companies allow their case managers to retain their ability to do their jobs with their clients based on the clients’ needs and not force them into cookie cutter forms. That is where you lose the real benefit of a nurse’s knowledge, experience and caring.

I also think case management is a very important tool that is often overlooked in making sure patients have the right care, and families have the information they need and that everyone is on the same page. Planning for the future is getting more and more important with our economic upheavals and the aging of our population. I hope geriatric care management continues to grow and become more well known so more families can take advantage of our expertise.

Click here to learn how you can be featured in one of our Case Manager Profiles.