PRE ACUTE CARE SERVICES
(preventive care)

Primary care physicians need a place to refer patients prior to sending them to the hospital ER or admission office. The hospital may also want to discharge the patient from ER without a short stay admission looking them in the face.

Pre acute care embraces the concept of preventing an unnecessary hospitalization. Currently 45% of the elderly patients are misdiagnosed and sent to the ER prematurely because there is not an alternative. Other times, they are put on observation and later sent back home or to the nursing home.

All-American Care has developed a "Pre-Acute Care" program that allows the primary care physician to admit the patient to one of our facilities, with a specialized unit for establishing a care plan and a discharge plan back to community based services. The doctor can bill Medicare Part B, and make the office visit a home visit, which can result in the patient's stabilization, while not requiring an expensive and debilitating hospitalization.

Our specialized services include:

  1. Preadmission screening using our comprehensive assessment instrument that electronically assesses the patients deficits, generates an appropriate list of triggered problems and causes along with the interventions needed to bring the patient back to their highest level of functioning without an acute stay.
  2. Electronic outcome based care plans utilized that trigger the patients into skilled nursing restorative and psycho/social programs carried out by licensed therapists, nurses and social workers to restore functioning to its highest level. These computerized records can be provided to the attending physician for further tests and orders as determined by the pre acute care team.
  3. Social worker involvement for the discharge planning process (upon admission), conducted with the family, so the physician can determine what the next steps are if the patient in fact does require acute care.
  4. Dietician involvement for recommending and preparing nutritional plans for those that are under or over weight or having problems with swallowing and digesting their meals.
  5. Skin care and wound care specialists’ involvement to prevent breakdown or heal the skin if it is jeopardized upon admission to restore functioning to its highest level.
  6. Occupational and speech therapy specialists involvement to assess mental and cognition status and put in motion programs to upgrade the patients’ memory and decision making skills and restore functioning to its highest level.
  7. Physical and respiratory therapists’ involvement to assess patients strength and abilities for ambulation and exercise and put in motion programs to increase strength and reduce shortness of breath under exertion and restore functioning to its highest level.

Expected Outcomes:

  1. Reduce the incidence of having to send a patient to the hospital ER or admitting them to an acute care setting prematurely.
  2. Raise the patients functioning to a level so they can return to the community based setting without an unnecessary hospitalization.
  3. Give the family and physician an option for restoring the patient before endangering them with the possible implications of an unneeded hospitalization.
  4. Allowing the family and physician to decide if the patient needs to stay in a long term care environment after being evaluated against the outcome goals set by the pre acute care team.
  5. All and all this lowers the cost of care and improves the patients’ chances of staying independent at home or in a supportive living arrangement.
  6. Allow the patient and family to preserve valuable resources that are spent on episodes that need better assessment and evaluation before spending the limited health care dollars on testing and medications that may not be necessary after following our pre acute services.

PAYMENT:

  1. We will bill the patients’ insurance for medical and therapeutic services, Medicare Part B for ancillary services and the patient’s account for the balance.
  2. Under Part C Medicare the Medicare Advantage companies will allow for Part A coverage without a hospital stay so under that arrangement the stay is free if that policy does not have a copay or deductible.
  3. Under Part A Medicare, the patient will require a three day hospital stay for receiving extended skilled nursing care.

 

POST ACUTE CARE SERVICES
(transitional care)

After a hospitalization the primary care physician needs a place to refer patients prior to sending them home or to an assisted living facility.

Post acute care embraces the concept of preventing an unnecessary re-hospitalization. Currently 85% of the elderly patients are re-hospitalized up to 5 times per year and sent to the ER prematurely because there is not an alternative.

All-American Care has developed a "Post-Acute Care" program that allows the primary care physician to admit the patient to one of our facilities, with a specialized unit for establishing a care plan and a discharge plan back to community based services. The doctor can bill Medicare Part B and make rounds as they do at the hospital in a less institutional setting that can result in the patient's stabilization while not requiring an expensive and debilitating re-hospitalization.

Our specialized services include:

  1. Preadmission screening using our comprehensive assessment instrument that electronically assesses the patients problems for the development of the causes and interventions needed to bring the patient back to their highest level of functioning without another acute stay.
  2. Electronic outcome based care plans utilized that trigger the patients into skilled nursing restorative and psycho/social programs carried out by licensed therapists, nurses and social workers to restore functioning to its highest level. These computerized records can then be provided to the attending physician for further tests and orders as determined by the pre acute care team.
  3. Social worker involvement for the discharge planning process (upon admission) conducted with the family so the physician can determine what the next steps are if the patient in fact can return to the community.
  4. Dietician involvement for recommending and preparing nutritional plans for those that are under or over weight or having problems with swallowing and digesting their meals .
  5. Skin care and wound care specialists’ involvement to prevent breakdown or heal the skin if it is jeopardized upon admission to restore functioning to its highest level.
  6. Occupational and speech therapy specialists involvement to assess mental and cognition status and put in motion programs to upgrade the patients’ memory and decision making skills to restore functioning to its highest level.
  7. Physical and respiratory therapists’ involvement to assess patients strength and abilities for ambulation and exercise and put in motion programs to increase strength and reduce shortness of breath under exertion to restore functioning to its highest level.

Expected Outcomes:

  1. Reduce the incidence of having to send a patient back to the hospital ER or admitting them to an acute care setting.
  2. Raise the patients functioning to its highest level so they can return to the community based setting without an unnecessary hospitalization.
  3. Give the family and physician an option for restoring the patient before endangering them to the possible implications of an unneeded re-hospitalization.
  4. Allowing the family and physician to decide if the patient needs to stay in a long term care environment after being evaluated against the outcome goals set by the transitional care team.
  5. All and all this lowers the cost of care and improves the patients’ chances of staying independent and going home or in a supportive living arrangement.
  6. Allow the patient and family to preserve valuable resources that are spent on episodes that need better assessment and evaluation before spending the limited health care dollars on testing and medications at the hospital that may not be necessary following our post acute care services.

PAYMENT:

  1. If applicable we will bill the patients’ insurance first for medical and therapeutic services, Medicare Part A if the patient had a three day qualifying and Medicare Part B for extended care ancillary services received in our extended skilled nursing units.
  2. After Medicare Part A is fully exhausted we will bill Medicare Part B for ancillary services and the patient’s supplementary policy account or Medicaid for the balance.
  3. Under Part C Medicare the Medicare Advantage companies will allow for Part A coverage without a hospital stay so under that arrangement the stay is free if that policy does not have a co-pay or deductible.