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Continuum of care can be defined as health care settings that provide ongoing or longer-term management of patients after their initial phase of illness or condition has been treated.
Continuing management of patient care may be indicated for
· Management and follow-up of the healing or convalescent process
· Restorative services to allow a patient to return to their former baseline activities
· Ongoing care and management of chronic conditions
· Continuing treatment of acute conditions that have not yet been resolved
Patients are usually transferred to these settings following treatment in an acute hospital. Continuum of care settings include inpatient and outpatient rehabilitation, skilled nursing, home health, dialysis, and long term acute care hospitals.
RESOURCES
The Continuum of Care Committee is presenting reprints of articles created by the committee for the CHIA Journal. As an added value of service to our membership, we feel it is important to reproduce on the CHIA Web site those articles that are still relevant for easy reference. After publication in the CHIA Journal, each of the articles created by our committee in the future will be made available for your reference three months after printing. We hope that you enjoy having the knowledge of your Continuum of Care Committee readily at hand.
In California, Skilled Nursing Facilities (SNF) are encountering changes in the way the California Department of Public Health (CDPH) Licensing and Certification conducts its survey process. Recently enacted statutory requirements mandated periodic inspections of all long-term care faciliteis licensed in California. Surveyors will use two documents to accomplish these additional survey tasks:
State Licensing Survey Field Note
Cross Reference Index for SOM (State Operations Manual) and Title 22.
CHIA Journal articles
To view any of the following articles, simply click on the titles below.
Skilled Nursing Facility
Scope of CDPH surveys has been expanded for SNF (May 2008)
Culture change (April 2008)
Timeline for SNF MDS 3.0 announced (April 2008)
Using SNF online quality indicator trend reports (May 2007)
Continuum of care resources (March 2007)
Official coding guidelines expanded for post acute care (February 2007)
Long Term Acute Care Hospital
MS-DRGs and Long Term Acute Care Hospitals (LTACH) (February 2008)
Long term hospital care (October 2006)
Medicare Rehabilitaton Facility
What is an IRF anyway? (November 2007)
Medicare therapy caps: Implications for Rehabilitation and HIM Professionals (September 2006)
Insights to Coding and Data Quality articles are posted on the CHIA Web site. They may be viewed by Clicking Here.
Lumetra
Additional resources are available on the Lumetra Web site http://www.lumetra.com
In the Health Care Provider section of the homepage, select Nursing Homes and Home Health Agencies.
As part of the national Nursing Home Quality Initiative, Lumetra is Medicare's Quality Improvement Organization (QIO) for California. Lumetra offers training events, tools, and resources.
Nursing homes can find resources to improve selected quality measures and assist facilities transition from an institutional to a person-centered model of care.
Lumetra participates in the national Home Health Quality Initiative (HHQI) to improve the quality of care delivered by the state's home health agencies. Their current campaigns are directed toward the reduction of acute care hospitalization rates, improvement in dyspnea and other publicly reported quality measures, as well as ensuring that immunization status is included in the patient's comprehensive assessment. Lumetra also helps home health providers implement organizational culture change and telehealth technologies
Additional Web sites
http://www.calregs.com (select list of CCR titles) http://www.cms.gov/nursinghomequalityinits (click on MDS 3.0 or MDS 2.0)
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