Goal:

To assist individuals who qualify for a Nursing Facility Level of Care to be able to stay in their own homes or in the least restrictive environment with assistance, in the most timely manner possible.  Our goal is to complete 70% of assessments by the due date assigned to these assessments by the state. This in turn reduces the number of nursing facility and hospital/emergency room admissions.

Strategy Description:

Provide an evaluation to certify medically compromised individuals who would normally require nursing home care, to be able to stay in their homes with assistance.  We will do this in the most timely manner possible, by attempting to complete at least 70% of assessments by the due date. Based on the nursing evaluation, client must obtain a nursing facility level of care.  Financial criteria is also required, meaning client must have Medicaid. Administrative Support will be utilized to call medical offices to request medical records, thus freeing up nurses time to complete the assessments in a timely manner. AERS is also is charged with nurse monitoring the clients in this program to make sure their needs are being met.

Level of Change:

Programs

Primary Focus Area:

Access to Care and Linkages to Community Resources

Data Category Tag:

GCHD AERS

Strategic Planning Alignment:

Customer Service

Estimated Implementation Date:

2017-07-01

Estimated Completion Date:

2022-06-30

Estimated Ease of Implementation:

Moderate

Estimated Cost of Implementation:

Moderate

Potential Community Benefit:

High

Health Equity:

Low income patients are getting better access to care, reducing the need for acute care, such as emergency room visits.  Patient's are more regularly getting to physician appointments, getting needed equipment and testing, and better access to mental health services.  All at a lower cost than inpatient hospital stays or nursing home stays.

Research:

This program is effective because there are now over 150 clients who qualified for a Nursing Facility Level of Care, meaning medically they could qualify for nursing home care. Instead of having to move into a nursing home, these people are able to stay in their homes or the least restrictive environment, with assistance from a Medicaid paid caregiver, oversight by nurses from the caregiver agencies, and nurse monitoring by the health department nurses.  This program also reduces hospitalizations/emergency room visits due to the client receiving the additional support in their home or in the least restrictive environment. The data reported is collected from the following sources: Objective 1:1,  % of Assessments completed by the due date, is from a report in PatTrac , located under Clinic Reports, and titled Referral Log Clinic Analysis. Objective 1:2, # of completed assessments is obtained from a list maintained by the office administrator and reviewed with nursing staff Objective 2:1, # of patients receiving services in the current month - obtained from a report in PatTrac titled AERS Caseload by Program and Service Area. Objective 2:2, # of Nurse Monitoring Visits completed in a month - Obtained from the nurses, self-reporting Objective 2:3, # of Nurse Monitoring Units completed and billed in a month - Obtained from a report in LTSS, under Activity & Billing Reports, entitled SPA-NM Activity Report. Units are calculated based on how many minutes each activity required.