Coordinating a Successful Turnover to Home Care Agency

 Join Jennifer Brullo, President & CEO of VNS of Westchester, and Colleen Martin, Administrator at King Street Rehab, as they share their expert perspectives on coordinating a seamless and successful turnover to a home care agency. Learn best practices, common challenges, and actionable strategies to ensure a smooth transition for patients and their families. 

Transcript

SPEAKER_05 0:00

you've lived well you've worked hard to make your place in this world your dignity and security are earned and well deserved or maybe you have a loved one who needs you more than ever well we can help you help them plan life better Welcome

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to Eldercare on the Air, a weekly radio show with guests in the fields of eldercare, special needs, financial services, independent living, and yes, people just like you. Where we will empower you to make sound choices when you're faced with an eldercare or special needs crisis. My name is Michael Amoruso, an elder law and special needs attorney with Amoruso & Amoruso in Rybrook, New York, which services clients in New York, Connecticut, and Massachusetts. You're at our new home, 107.1 The Peak. But I do encourage you to go onto our website, eldercareontheair.com. That's eldercareontheair.com. Click on the radio show tab you see. and just simply download the episode you'd like to listen to. You see, this show is designed to arm you with the knowledge and tools that you need to make sound choices to help you or a loved one age in place. If you have any questions or would like to hear topics on future episodes of Eldercare on the Air, please send us an email at info at eldercareontheair.com. That's info at eldercareontheair.com. In this episode, we're going to try something a little new I want to give all of you out there. How many of you are a loved one who needs short-term rehab with the intention to go home? We need to help you. How that hands-off goes, short-term rehab, back out into the community. So with that, I'm thrilled to have here two guests with us. The first is going to be Colleen Martin, who is the Assistant Administrator for King Street Rehab. Colleen, welcome to our

SPEAKER_01 2:41

show. Thank you, Michael. natural lighting in the building, so it's a holistic approach. I think it's important that it's family-owned, with the family being present day-to-day and operating as if they're one of the staff members doing everything that goes on from the moment the residents wake up to the time they go back to bed at the end of the day.

SPEAKER_03 3:08

Colleen, at your facility,

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help

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the audience understand the difference between short-term patients versus older.

SPEAKER_01 3:16

Sure. Residents that come in for short-term rehab are clearly just that. They're coming in from a hospitalization, whether it's a medical issue or orthopedic issue or something that required a hospitalization, that's not really ready to go home but needs some rehab to get them stronger, back to the baseline to which they had prior to the hospitalization. They come in for rehab services, occupational, physical, speech therapy. And then once the goals are achieved, then it's time to send them back home into the community with their families, whatever they were doing prior to the hospitalization to resume their independence to the best of their ability.

SPEAKER_03 3:49

I think you

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hit

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on an important point there. So they're coming to you from the hospital, and how do you define goals to be achieved? What does that mean to you?

SPEAKER_01 3:58

So basically, within the first 24 or 48 hours, evaluations are happening and assessments by the team, whether it be the therapists or the nursing or the physicians. And from there, we come up with what their level of function was prior to the hospital, usually through interview and conversations with family, friends, representatives, or even the resident themselves. And then we see where they are functionally at that time on the evaluations and assessments. From there, then, we set the goals. Very basic and simplistic goals. We want them to be able to transfer from laying down to sitting at the edge of the bed, sit to stand, getting to the bathroom, meeting their basic needs, which is so important day to day that we forget about until you can't do them by yourself anymore.

SPEAKER_03 4:38

Exactly. And what are some of the services that you offer to help people achieve these goals?

SPEAKER_01 4:44

Well, we have, like I said, the rehab staff. So we have rehab on site six and seven days a week. We have nursing care that is provided throughout the whole 24 hours. And with that, we utilize the staff, the certified nursing assistants that might help the resident get up in the morning, get washed, get bathed, get dressed, get to breakfast, begin to their daily activities of life. by incorporating what rehab is working with them on, such as the balance, the transfers, the ambulation with a walker, maybe wheelchair mobility, things to get them back into a routine that mimics closer to being home, that gives them the strength and everything they need to be to be able to feel that they can go back home again.

SPEAKER_03 5:21

Typically, based on your experience, how long does the short-term rehab process often take?

SPEAKER_01 5:28

It could take anywhere from two weeks to six weeks to eight weeks, whatever it might be, but the Key thing to remember is what's the skilled need that's causing them to stay? What are we doing in our building that can't be replicated at home? You know, so we are giving aggressive rehab services. You can have rehab services at home through the home care agency. It's a little bit less than what you would get in a facility, but it's the continuation of care. We do much more in the beginning to get you stronger, to be able to get you back home and to have services at home or even go outpatient for services, depending on what your skill level is.

SPEAKER_03 6:02

Excellent. Now, I'm sure you must sense anxiety of family members or even the patients themselves once they start to get an inkling that discharge may be coming

SPEAKER_01 6:14

close. I think it's very important. It's all about communication. Communication from the facility to the resident and the family and vice versa. I think we see a resident coming in according to a diagnosis that caused them to go to the hospital. We don't know everything else that's coming with them. And that's important that the communication of questions and concerns get answered early on, and the plan basically kit around discharge begins on the day of admission, understanding what it was like, what the resident was home, and what we can do to make them to get back to that environment as quick as possible.

SPEAKER_03 6:43

And I think you just hit on something there. You guys have to dive into what their home environment is like, correct?

SPEAKER_01 6:51

Correct.

SPEAKER_03 6:53

So the more transparent your patients can be or the family members of your patients can be as to what... to expect at home, the better the advice you can then give what may need to be adapted, if anything, to make sure it is a safe discharge back home.

SPEAKER_01 7:11

It's very true. And I think when we ask families or residents, how were you able to walk? How were you able to meet your needs? How were you doing everything you're saying you were doing before going into the hospital? We're talking about that immediate moment. I don't like to hear about, well, eight years ago, I was able to walk up and down five flights of stairs. That was eight years ago. Reality is, what were you doing right before the hospital? Because that's what we consider what's called the prior level of function.

SPEAKER_03 7:37

Yeah, you're living on the first floor

SPEAKER_01 7:38

only now. Right. You're not doing stairs. Or I have my daughter does my food shopping, and I have someone that checks on me for some help. That's important to tell the staff because that's what they're going to work on. The goal of independence might be there. It might not be there. But that doesn't mean we then can't plan for the support that you need that actually can keep you as safe as possible at home.

SPEAKER_03 7:57

Right, because under the Medicare regulations, Department of Health regulations, your job is to get them back to the best you can to basically where they were before they entered the hospital, not in their best case scenario.

SPEAKER_01 8:10

Right. We all think we could do better, but reality is I might not be 100%. And that's okay. Or I might be 100% three out of five days, but I still need help or I have to have provisions in place for those two days. And I think that's very important, that communication with the therapist, communication with the nurses and the social worker when they're talking to you. So it's important within like 72 hours to seven days, 10 days after admission, you're going to have what's called a care plan meeting. That's the meeting where you get all the conversation happening of how that loved one is doing, what the expectation is, what the goals are going to be, and what that anticipated discharge date might be. You've got to work towards it. We don't like to surprise anyone. You want to have that use of that conversation early on. So whether they left in three weeks or six weeks, you have a plan and knowing what that plan is going to be when you walk out from that care plan meeting.

SPEAKER_03 9:00

Excellent advice there, Colleen. Excellent. So now let's talk about some realities. Discharge is coming close. Next step is to make sure that it's going to be a safe discharge. Many times there's got to be a handoff to some kind of a home care agency or a home health aide to help the individual. How do you start that dialogue with the family and inquire as to whether this can be covered under Medicare or private pay or whether they may need to be seeking other services like Medicaid home

SPEAKER_01 9:34

care? So that conversation at that care plan is where this comes into play. Because the therapist and the team that's been working with that resident will have a good sense of what they're going to need, whether it be three weeks, six weeks, eight weeks down the road. And sometimes that doesn't fit what the resident and the family were thinking they'd really need. Because in the conversation, you'll find, yes, I agree with you, mom and dad have been having more and more trouble, and they really shouldn't be left alone at night. So under Medicare, you're only entitled to certain services. So when it exceeds that, we talk about the fact of if there's financials where they would be able to afford private help. agency work? Do they have a long-term care policy that they need to initiate? Do they have anything within their retirement packages that might have some sort of catastrophic event coverage? And then this way you start to piecemeal it. But really the most important handoff is going to be that home care agency. So the question usually is asked, have you been connected to one in the past? Are you happy? Or if you've never been connected, okay, these are our options. And you give options. And then you hand off to the home care agency. We try to do it at least a week before discharge. This allows them to have the paperwork that's required for them to review the case, to see what the hospital situation was like, to see how they've managed themselves at our facility, and then see whether they can manage that case or not. We then ask them that one of their liaisons come into the building to see the resident, because it's the fear factor. the unknown ahead of them, and that if they can put a face to a service to understanding that I have a lifeline when I leave, then I think that makes it so much easier for them to help and participate actively in their district.

SPEAKER_03 11:05

I think that's very well said. Now, what goes on behind the scenes that the family's not seeing as you're communicating with the home care agency? You're making a judgment as to whether this agency would be the appropriate fit for the family as well or the patient. So what can you tell, enlighten the world about what's going on there in that

SPEAKER_01 11:26

dialogue? Well, obviously, there's a lot of different home care agencies out there that everyone works with. The key is that do they accept the insurance and how quick they can get in post-discharge and what services they think they're going to be able to provide their residents. So that's why that important moment when they come in the building, see the resident, see the paperwork, hear from the team what they think is going to be needed, is what they can put in place. Unfortunately, you know, the pandemic did a lot of different things to a lot of different aspects of health care and staffing for every aspect of it has been affected. Some home care agencies might not be able to get in there right away. But this family really wants that home care agency because someone that they knew had them and they're willing to wait. Okay, great. You can wait it out. But what you're going to need to bridge them between home and when that agency starts is still just as important. needed than what the insurance is providing, then that home care agency needs to be able to support that as well. So such as us saying, okay, this is what they're going to need. We're going to need a social worker on the case. Can you help manage it? Can you help assist them getting other services? If the answer is no, then that's not the agency for them. But there are other options because in that too, there's still that wait period. So we also use and recommend a lot what's called Westchester Stable on the Move. That is a free service to the family and the residents and assistance in getting community Medicaid. I think that's important as well. That's a process too, but you have one that could be a free service if there really is no financial ability to pay for it versus also the other aspect of using a home care agency that can assist with the process. But there's, again, that conversation that needs to be had between the resident, the family, and that home care agency, exactly what needs to be done.

SPEAKER_03 13:26

And the transparency from the family to you is vitally important so that you can pair them with the right road to go down.

SPEAKER_01 13:34

It's communication with strangers. You're taking a leap of faith. You're going into a building with not knowing what to do, how to navigate a system that is not a system that's easily navigated and trusting people that you don't know. So that's why as much as I say it's communication, it's not an easy communication, but it has to be reality based. And I think that's so important. Nothing any family is ever going to say to a team that's been established that will say anything other than how can we help you. And that's what's important. How can we make sure that we make it as safe as possible, knowing that even the safest plan still might not be possible, but you want to give that resident the opportunity to be back home in the environment to which they've thrived in, they've lived in, and you know, more than anything.

SPEAKER_03 14:15

Colleen, it's been wonderful to have you here to explain this initial handoff. How can folks, if they've got questions, reach out to your facility or if they want to recommend to a discharge planner at the hospital that that they want to get rehab at your facility, what do they need to do?

SPEAKER_01 14:32

Sure. So basically in the hospitals, you just need to tell the discharge planners that you would like information sent to King Street Rehab, which is in Rybrook. In all the hospitals in this area, Westchester Medical, White Plains, Greenwich, Northern, we're well known. We're part of the team. So they can send paperwork. And then our team will look at it and see whether or not we can manage the case safely. Because again, we want to make sure that it's a safe ability to be managed and to hand off. We're also located and set in Redbrook, but our phone number is 914-937-5800. And you can also Google us.

SPEAKER_03 15:04

Excellent. Colleen, we're going to take a quick commercial break. When we come back, we're going to bring VNS of Westchester on here, which would be the hypothetical situation here where the handoff would occur to. We're going to learn more about the home care agency side of things. So if you miss any part of the show, just log on to our website at eldercareontheair.com. We'll be back in a few moments.

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Amoruso and Amoruso LLP advises clients on how to obtain public benefits, including Medicaid, and more importantly, how to protect and preserve their assets, whether they be modest or significant. Find Amoruso and Amoruso online at eldercareontheair.com. Amoruso and Amoruso, a 107.1 The Peak Ask the Expert partner.

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Amoruso and Amoruso, empowering you to care for the ones you love.

SPEAKER_03 15:53

Welcome back to Eldercare in the Air. I'm Michael Amoruso. And again, I'm thrilled to have you all here. And if you missed the first half of this show, let me just give you a little roadmap of what we're doing here. We're talking about the handoff between short-term rehab facilities to home care agencies back home to ensure that when you get home, you stay there. You don't go through the revolving door that many of us have seen where you get discharged from a facility, go back home, back into the hospital, back to short-term rehab, back home. That's that revolving door we want to prevent. One way to help try to prevent that is to ensure that there is an appropriate handoff between the short-term rehab facility and a home care agency. And with that, I'm thrilled to have here Jennifer Brulow, who is the new president and CEO of VNS of

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Westchester.

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So Jennifer, welcome to our show.

SPEAKER_02 16:49

Thank you, Mike. I'm very excited to be here. I appreciate you having me.

SPEAKER_03 16:52

It is great to have you here. So tell us a little bit about VNS Westchester.

SPEAKER_02 16:56

Sure. VNS Westchester has been serving Westchester and the surrounding counties for almost 125 years. We provide a large scope of home health services that can help patients no matter what part of the care continuum they're on. And we have amazing caregivers, nurses, therapists, as well as home health aides.

SPEAKER_03 17:20

And you've got essentially two branches, right? You've got a CHA side, and I'll let you define what that means. And then you have an ELIXIR side as well. I'll let you define that. Why don't you tell that to you?

SPEAKER_02 17:32

So the CHA is our division that provides skilled services through Medicare and other insurances. So in order for a patient to qualify for CHA services, They need to be homebound. They need to have skilled needs, such as require some type of nursing-skilled care or therapy services. Then under the personal care division, also known as the LHCSA or licensed home care agency, that's primarily personal care services. So that can be paid for privately. Through managed long-term care insurance, we do have some community-based contracts. Even long-term care insurance will pay for that service. And so you may receive home health aid services. We also have available skilled nursing services that could be paid for privately.

SPEAKER_03 18:19

And if someone was on Medicaid, they would be on that side of

SPEAKER_02 18:23

it. That's correct. They may also receive care under the CHA in a limited capacity, but primarily if it's long-term needs, it will be provided under the licensed home care agency.

SPEAKER_03 18:34

Excellent. So Jennifer, before I had you come in here, we had Colleen from King Street Rehab. And Colleen was explaining the process of getting a patient typically through a hospital, setting goals for that patient for discharge, so that they're rehabbed to a point so they can be safely discharged home. And about a week before discharge, they would reach out to home care agencies like yourself. And what happens next? How do you pick up that ball?

SPEAKER_02 19:06

So generally, once we receive a referral from a nursing home like King Street, it's important to remember that care doesn't just end at the nursing home. They've done an amazing job getting the patient prepared to return to community-based living. But that continuity of care needs to continue to make sure that patient can remain independently in the community and learn how to function in their true environment. And so when we receive the referral, we review the information to determine whether or not the patient has what we call a skilled need. So they need some kind of nursing or therapy service. And it's the criteria for a CHHA episode. If in fact they do, We will also send a representative to the facility so that we can look through the record, make sure that we have all of the pertinent information that we require, as well as have a chance to meet the patient and or family, get them comfortable with our team. And so that creates a warm transition. And so once we determine, yes, that patient is ready to come on care, we get the referral. We're usually seeing that patient for the first CHHA visit within 48 hours in their home where either our nurse or therapist is completing a comprehensive assessment under the Medicare guidelines.

SPEAKER_03 20:22

So within typically 48 hours of the moment they're discharged or the day they're discharged. Got it. What happens in that bridge period from discharge to when you would officially show up? How can they fill that void?

SPEAKER_02 20:38

So if a patient realizes that Home care is not coming in for 24 to 48 hours, but I'd feel more comfortable having someone in the home. Maybe they need some assistance, what we call activities of daily living. So things that we take for granted that we do every day, like bathing, grooming, meal preparation, medication reminders. We can arrange with our licensed home care agency to have someone even pick them up at the nursing home and accompany them home get them ready and prepared for when the CHA actually comes in. And so when the CHA does come in, again, it's usually either a nurse or a therapist, completes the assessment and determines what the plan of care will be. Sometimes patients feel more comfortable even supplementing the care they're getting through Medicare. Medicare only covers a limited number of home health aid hours, and some patients want more than that. Maybe they have an available caregiver who also has children of their own or other responsibilities. And so while they're involved, they're not there as frequently as they want someone to be in the home. And so we can work in tandem with our licensed home care agency to be able to supplement those services to make them feel as comfortable as possible.

SPEAKER_03 21:54

Excellent. And what is your communication like with the rehab facility to really understand where this patient was and how they rehab to the point of discharge and sustaining them or maybe helping them improve further once they're home.

SPEAKER_02 22:11

So that's a really important conversation for us to be able to have with the nursing home because we want to understand their medical history. We want to understand what happened before they actually got to the nursing home, what type of care was being delivered in the nursing home, what medications they're currently taking, any equipment that they've been utilizing in their nursing home that they might need in the home now that they're in the community. And we want to understand what their functional limitations might be because that will help us to figure out exactly what kind of care they need and inform our care plan. And so that's why it's very important to have very tight communication with the nursing home because we want to make sure that there's continuity of care. That patient has already made progress in their treatment and we don't want that continuity recovery to be stalled at all. We want to continue to see them on that road to recovery. And I think it's important to point out that when they're in a nursing home, they're in a very structured environment. And so things are timestamped. They know when they're getting certain services or treatments. And now they're in the home. And so things are very different. No one's preparing their meals. We need to assess all of that to understand what limitations could potentially hinder their recovery. And so that's what makes home care very unique because we're seeing the patient in their true environment and we have that opportunity to help them really gain independence and for them and their family to be involved in that plan of care to make sure that not only are our goals of treatment for them met, but what they want to do again in the community, they're able to get to. I

SPEAKER_03 23:51

think that's very well said because my next question was going to actually be they're leaving this protected, structured environment as you framed it as. And... maybe they're on their best behavior because they want to be discharged from rehab and they're trying their hardest. Now they're back home. And sometimes the old routines will kick back in. So what are some things families and the patients should expect out of home care versus what they should not expect from home care services?

SPEAKER_02 24:22

So one of the most important things to understand is home care's job is to help a patient regain their independence. And so it doesn't mean in most cases that we're going to be in there for an extended period of time. And so this really is about how do we educate you and give you the tools and resources that you need so that when we leave, say, in 45, 60 days, you feel confident that you will be successful and independent living on your own. And so we leverage all of the resources that we have available. And so we're identifying what are the skilled nursing needs that you need? Do you need medication education? Do you need pre-pores of medication so that we make sure that you're adhering to your medication routine? Do we need to teach someone in the family how to do wound care for a patient on an ongoing basis? What type of exercises from a physical therapy perspective will be important so that someone can ambulate well, to be able to navigate the stairs as they're going through the community, be able to go outside and enjoy a walk where they didn't have that opportunity before? And then even from a social work perspective, what are the community resources available to them that we can link them to so that when we leave, They have these opportunities and this knowledge at hand, and that helps them to be independent in the community.

SPEAKER_03 25:52

Yeah, you're integrating them back into a life that they once enjoyed.

SPEAKER_02 25:57

Absolutely.

SPEAKER_03 25:58

Wonderful. So let me ask you this. Someone's in a rehab facility. They didn't expect they'd be there. How can they find their way to BNS? What do they do?

SPEAKER_02 26:12

They should have a conversation with the discharge planner at the nursing home, with the social worker, understand what their options are related to home care. They can certainly visit our website. And if you look on CMS Compare, you can even look at the ratings of home care agencies in your area. So you can see who has the highest patient satisfaction rating, who's a five-star agency compared to a two-star agency. And so education and really getting resources at your fingertips where you can figure out what's the best choice for me or for my family member is really important when you're making that decision to move forward. And who can help guide you no matter what your needs are? And so is this cha linked up with Elixir where I'd be able to supplement services? Do they work collaboratively with other hospitals or nursing homes in the community so that if something changes, they're able to quickly link me to the care that I need. That's really important. You want to make sure that someone who's delivering care in the home is well-resourced to be able to help you navigate what we all know is a very difficult process for people.

SPEAKER_03 27:22

Jennifer, excellent information. One last time, tell them how to find you.

SPEAKER_02 27:27

Sure. So please check out our website. It's www.vns.org. Take a look. We have a lot of wonderful patient testimonies. And if you ever need our services in the future, we very much look forward to caring for you and your family.

SPEAKER_03 27:45

Excellent. Jennifer, thank you for joining us. And I hope all of you out there really enjoyed a little twist on this one. Instead of just highlighting... a nursing home or a rehab facility or just a home care agency, we really wanted to educate you this time how that a proper handoff should occur between the short-term rehab and the home care agency. So hopefully you only have one visit at that rehab facility and you can enjoy the fruitful life that I know Jennifer and VNS want you to have back out in the community and hopefully gain as much independence and integration as you once enjoyed it. If you missed any part of this episode, just log on to our website at eldercareontheair.com. I look forward to speaking to you all next week. Be safe. Be well.

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Amoruso

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and Amoruso LLP and Rye assists clients with comprehensive estate planning and vital asset preservation tools that reduce financial risks of long-term care. Amoruso and Amoruso, a 107.1 The Peak Ask the Expert partner. Visit eldercareontheair.com for more details.

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Amoruso and Amoruso, empowering you to

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care for the ones you love.