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TRANSITIONS OF CARE

TRANSITIONS OF CARE. Jenny Quigley-Stickney RN MSN MHA CCM Jordan Hospital & Tufts Medical Center Case Management Society of New England May 2, 2011 . Management of the Acute Injury. Acute onset of injury ED admission Triage to Trauma Center Critical Care Unit Medical Surgical Unit

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TRANSITIONS OF CARE

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  1. TRANSITIONS OF CARE Jenny Quigley-Stickney RN MSN MHA CCM Jordan Hospital & Tufts Medical Center Case Management Society of New England May 2, 2011

  2. Management of the Acute Injury • Acute onset of injury • ED admission • Triage to Trauma Center • Critical Care Unit • Medical Surgical Unit • Transition to Rehabilitation Center

  3. Transition to Rehabilitation • Determination of patients prognosis and level of care • Evaluation of cognitive and functional recovery • Fiscal resources • Family support and provisions for care

  4. Levels of Rehabilitation • LTAC admission criteria • Acute Rehabilitation admission criteria • Skilled level of care and admission criteria • Home Rehabilitation care

  5. Time Frames for Rehab recovery • LTAC provides acute medical care and rehabilitation for ELOS of 30 days or more • Acute Rehabilitation care (IRF) ELOS of 20-31 days • Skilled level of care ELOS 2 weeks to 100 days • LTC in nursing home private pay, MH or LTC policy for additional nursing and 24 hour care

  6. Case Management in Rehabilitation • Assist with reviewing insurance and determine additional needs for insurance • Assist with accessing resources for LTC policies, STD, LTD and need for FMLA • Assist in accessing SSI and SSDI resources • Introduce Mass. Brain Injury Association and resources • Complete SHIP application and acknowledgement of new Brain injury • Complete PCA application if eligible

  7. Transition to the Community • Criteria for safe transition to the community based on FIM, cognition and behavioral management of the TBI survivor • Supervision provided in skilled level of care, family through FMLA, PCA program, LTC policies and private pay HHA • Discharge to home with home care or outpatient rehabilitation, Skilled level of care, Foster care and TBI Group homes

  8. Transitions Guided by Resources • Insurance coverage • Fiscal availability and Private funds • LTC plans • Family availability for supervision and hands on care • Family understanding on TBI and management of behavior , cognition and substance abuse issues

  9. Challenges for Transitions • Supervision • Management of Behavior, Cognition and substance abuse issues • Fiscal challenges for care provision • Gaps in care from rehabilitation discharge and safe management of the survivor in the community • Case management assistance with modifying care plan as the survivor copes with challenges living in the community

  10. Future Development • Electronic devices for safety monitoring • Development of outcome criteria for Transitions of Care • Development of Day Programs for brain injured survivors • Increased development of group homes designed to retrain survivors for re-learning and independent living.

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