Imagine that you are a new short-term guest in a Skilled Nursing Facility (SNF) for rehabilitation and nursing services. After you move in, you go through the admission process. It includes a lot of information, some of which you may or may not eventually recall; you are just happy to be out of the hospital and in your own clothes. Over the next few days, you go through the various introductory interviews with the SNF staff, including the dietician, social worker, therapists, and nurses. Many of these people ask you the same questions, leading you to wonder, “Are these people talking to each other?”
This annoyance notwithstanding, you end up getting most of your questions answered and have an idea of what is going to occur over the next couple of weeks. These weeks go by without another formal discussion about your plan of care, your progress, or your plans once you leave the SNF. You are not sure how your recovery is going in the minds of the SNF decision makers, and you have some lingering questions and concerns that have not seemed important enough to bother anyone about. You are generally content with the SNF and the rehab and are not seriously thinking about going home yet.
At the beginning of the third week, the social worker talks with you about setting up a care conference with your important family members. During this conference, you hear that the therapists and nurses believe that you are physically ready to go back home. This comes as a bit of a surprise to you and your family. There are a number of barriers to a smooth transition home that could have been addressed much earlier had you been offered a forum in which to share your situation, and your lingering questions were found to be quite important. The SNF decides you need to stay an extra week to resolve these barriers to the transition home.
Alternatively, imagine that during the admission process the interdisciplinary team (IDT) invites you and your important family members to meet with them once per week, every week, until you go home. They refer to this discussion time as Grand Rounds. The Director of Rehabilitation (DOR) leads the discussion, which makes sense, since you are at the SNF for rehab in order to return home. The idea of Grand Rounds eases your mind. You will get to show the IDT your progress, reiterate your goals, and discuss the questions you may have. The team will get to review any concerns they have with your progress or goals. You will be included in the weekly management of your care while at the SNF, and all parties concerned will understand your goals, wants, and needs in preparation for a smooth transition back home.
The second scenario describes a program called “Grand Rounds” or “Progress Rounds.” Cindy Benfield, Healthcare Administrator at Good Samaritan Loveland Village, and Melissa Riehl, Loveland’s Director of Rehabilitation, have recently transitioned to Grand Rounds at their SNF. Cindy says they are quickly realizing many benefits. “Compared to the traditional Medicare meeting system and inconsistent Care Conferences, we have found that Grand Rounds strengthen the relationship bonds between our care givers and those we serve. Additionally, we’re finding valuable time savings for our often overwhelmed staff.”
Cindy describes an additional benefit to holding Grand Rounds: Streamlining patient management meetings. The randomly scheduled Care Conferences with families have all but disappeared, and the various phone calls and on-site visits to social workers from family members have drastically reduced in number. Melissa has noticed the enhancement in communication, “Family members at Loveland Good Samaritan have been very happy with the increased communication with staff, and Grand Rounds are quickly becoming our best resource for relaying information between all the important parties, including the guest and their family members.”
As ideal as this sort of system sounds, it is not always easy to move away from the traditional IDT-only Medicare Meeting. Sara Dent, Administrator for St Paul HealthCare Center in Denver, Colorado, explains how their team managed the change, “Because Grand Rounds aligns with our person-directed values, we were in agreement that we had no choice but to move to it. We knew that there would be problems and challenges to overcome, so we said that we were going to try it for three months, no matter what. We’re now one month into it. While we have had to make a number of adjustments and refinements along the way, we now average only seven minutes per guest discussion.”
Besides being person-centered, Grand Rounds is a system that may align with the future of healthcare reimbursement incentives. The days of 30-day Skilled Lengths of Stay appear to be ending, and a financial premium will be placed on quality, specifically, patient satisfaction. SNFs will need to help assure that re-hospitalizations do not occur even after patients leave the SNF. They will be accountable for up to 30 days following the hospital discharge, yet might only have the person under their roof for 20 days. Grand Rounds serves to assure a coordinated, client-included process that aims to remove barriers to health improvement efficiently, and then prepares the person to successfully transition out of the SNF. It begins this process early and maintains it each week.
Does this sound like something that might benefit your SNF? Do you have a strong dedicated DOR that could lead this sort of weekly discussion? If so, here are ten lessons learned from the St Paul and Loveland Good Samaritan experiences:
Start by gaining buy-in, or at least understanding, from the IDT as to the overall rationale for the change. Keep these reasons in front of people as they struggle to make Grand Rounds work.
Rather than demanding the change at once, suggest a trial, and then commit to a time frame. People may be more agreeable to a trial and before you know it, they will make it their own system.
Be flexible on whether or not you will ask the team to travel room to room or if you will have each client be transported to one location to meet with the IDT. Either method may work.
Clearly communicate the Grand Rounds system to each client and family. For everyone to get the full value out of it, people need to understand that Grand Rounds is the preferred time and place for them to communicate with the IDT. St Paul and Loveland Good Samaritan provide a short explanation letter within their admission packets, and then the social worker and DOR explain it to them again during their introductions.
Pragmatically make sure everyone understands the amount of time allocated for each client discussion. 10 minutes seems to be a reasonable ceiling. Both St Paul and Loveland Good Samaritan now average about 7 minutes per client discussion.
To respect family member’s time while allowing the team some flexibility, let the client and family know that their meeting will be within the period of an hour. For example if you have 12 skilled clients, you might tell 6 of them that their meetings will be between 9 and 10am, while the other 6 will have their meetings between 10 and 11am.
Typically, the DOR leads the discussions. This leader needs to address the important areas with each client, assure team and family members have a chance to speak, and keep people on task. While in this capacity, the DOR becomes an even more vital part of the SNF’s Skilled operations.
Do not be afraid of scheduling out individual family conferences for really complicated or sensitive situations. Grand Rounds may not meet the needs of every situation, but it has been found to cover the needs of the vast majority of skilled clients.
Allow the IDT to complete much of their paperwork during and between the discussions. Care planning can be completed, nursing progress notes can be written to support the skilled stay, even orders can be written. The meeting time can be billable for therapy if they document the skilled discussion, education, and problem solving that occurred. Sometimes, it may be appropriate for other therapists to attend a respective meeting..
Consider meeting as an IDT prior to Grand Rounds to review any notable situations quickly, so that everyone is on the same page. St Paul meets at 9:15am, and then begins grand rounds for about 20 skilled clients at 9:30am.
SNF Administrators and DOR’s may soon realize that they need to revamp vital patient management systems. Those that thoughtfully switch from the institutional Medicare Meeting to the patient-centered Grand Rounds will realize the benefits that come with enhanced patient and family involvement, while those that keep the status quo may struggle to successfully manage patients given a reduced number of days in which to do so. If you find yourself struggling to make sense of the change, put yourself in the patient’s shoes. What sort of system would you prefer?
Tyler Keeter PT, DPT, MHA is the Colorado Area Rehab Director for Infinity Rehab. He is also Adjunct faculty for Regis University’s Doctor of Physical Therapy program, teaching courses in business planning, professional advocacy, and service learning. Dr. Keeter has presented the concepts of person-directed rehabilitation at many conferences including the American Health Care Association National Conference, Colorado Health Care Association Conference, and the Nebraska chapter of Leading Age. He thoroughly enjoys supporting the therapists in the Colorado Region in the service of their residents and clients.
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WHO WILL FOLLOW THIS NOTICE
THE AVAMERE AFFILIATED COVERED ENTITY
This Notice describes the privacy practices of the Avamere Family of Companies Affiliated Covered Entity, including skilled nursing facilities, nursing homes, home health, hospice, home care, in and out-patient therapy, nurse practitioner programs and other health care providers and business associates that the organizations operate, as well as any health care facility or provider organization now or in the future sharing common ownership. These independent organizations are part of the Avamere Affiliated Covered Entity (“Avamere ACE.”)
Each of the Avamere affiliates is a separate covered entity under the Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder (collectively, “HIPAA”). A list of affiliated companies is available from this company.
Pursuant to 45 C.F.R. § 164.105(b), each of the Avamere affiliates hereby designates itself as a single covered entity for purposes of compliance with HIPAA and solely for purposes of compliance with the HIPAA Privacy and Security Rule. Each of the Avamere ACEs is an independent company and having accepted designation as an Avamere ACE does nothing to diminish that independent entity status. This affiliation does not apply to any other legal aspect of business operations or patient care.
The Avamere ACE is required under HIPAA to protect the privacy of your PHI, provide you with notice of our legal duties and privacy practices with respect to PHI and abide by the terms of the Notice currently in effect for the Avamere ACE. This Notice describes how the Avamere ACE may use and disclose your protected health information (“PHI”) and your rights to access and amend your PHI. This Notice does not cover the information practices of attending physicians or other providers not part of the Avamere ACE.
GENERAL DESCRIPTION AND PURPOSE OF THIS NOTICE
This notice describes our information privacy practices and that of:
Any Avamere ACE health care professional authorized to enter information into your medical record created and/or maintained at our affiliated health care companies;
Specific volunteers which we allow to help you while receiving services at our affiliated health care companies;
All health care company workforce members including, but not limited to, employees, contractors, staff, health care students, interns, and other personnel; and
Other entities under contract to assist in providing healthcare in a clinically integrated manner.
The above individuals and affiliated entities may share your protected health information with each other for purposes of treatment, payment, health care operations, or business associate operations, as further described in this notice.
AVAMERE ACE’S POLICY REGARDNG YOUR PROTECTED HEALTH INFORMATION
Certain state and federal laws and regulations require us to implement policies and procedures to safeguard the privacy of your protected health information. This notice will provide you with information regarding our privacy practices and applies to all of your protected health information created and/or maintained at our affiliated health care companies, including any information that we receive from other health care providers or facilities. The notice describes the ways in which we may use or disclose your protected health information and describes your rights and our obligations regarding any such uses or disclosures. We reserve the right to change the terms of this notice of privacy practices and to make new notice provisions effective for all protected health information we maintain. In the event of revision, new copies will be posted in the health care companies, on our website and available upon request.
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
The following are the types of uses and disclosures we may make of your health information without your permission. Where state or federal law restricts one of the described uses or disclosures, we follow the requirements of such state or federal law. These are general descriptions only. They do not cover every example of disclosure within a category.
We may use and disclose your protected health information to healthcare professionals or other third parties to provide, coordinate and manage the delivery of your health care. For example, we may disclose PHI about you to your health care provider or to other health care personnel to coordinate your transfer to another level of care within or outside of our affiliates. Our Affiliates may also access and view your health information in our electronic medical record systems. We will also disclose your health information to your physician and other practitioners, providers and health care facilities that provide care for you at their sites, rather than at our sites, for their use in treating you in the future. For example, if you are transferred from one of our nursing facilities to home health at discharge, we will send health information about you to the home health agency.
We will use and disclose your health information for payment purposes. For example, we will use your health information to prepare your bill and we will send health information to your insurance company with your bill. We may also disclose health information about you to other health care providers, health plans and health care clearinghouses for their payment purposes. For example, if you are brought in by medical transport, the information collected may be given to the medical transport provider for its billing purposes. If state law requires, we will obtain your permission prior to disclosing to other providers or health insurance companies for payment purposes.
Health Care Operations
We may use or disclose your health information for our health care operations. For example, members of our workforce may review your health information to evaluate the treatment and services provided, and the performance of our staff in caring for you. In some cases, we will furnish other qualified parties with your health information for their health care operations. The medical transport company, for example, may also want information on your condition to help them know whether they have done an effective job of providing care. If state law requires, we will obtain your permission prior to disclosing your health information to other providers or health insurance companies for their health care operations.
We may contact you as a reminder that you have an appointment for treatment or medical services.
We may contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.
While you are an inpatient at any Avamere ACE facility, your name, location in the facility, and religious affiliation may be included in a facility directory or its equivalent in our electronic medical record. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. You have the right to request that your name not be included in the directory. We will not include your information in the facility directory if you object or if we are prohibited by state or federal law.
Family, Friends or Others
We may disclose your location or general condition to a family member, your personal representative or another person identified by you. If any of these individuals are involved in your care or payment for care, we may also disclose such health information as is directly relevant to their involvement. We will only release this information if you agree, are given the opportunity to object and do not, or if in our professional judgment, it would be in your best interest to allow the person to receive the information or act on your behalf. In addition, if you are unavailable, incapacitated or in an emergency situation, we may disclose limited information to these persons if we determine in our professional judgment that we believe it is in your best interest. We may also disclose your information to an entity assisting in disaster relief efforts so that your family or individual responsible for your care may be notified of your location and condition.
Some of the activities described above are performed through contracts with outside vendors called business associates. We will disclose your health information to our business associates and allow them to create, use and disclose your health information to perform their services for us. For example, we may disclose your health information to an outside billing company who assists us in billing insurance companies. We require business associates to appropriately safeguard the privacy of your information. Examples of business associates include medical records storage companies, computer software companies and accreditation agencies.
USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION
Uses and Disclosures Not Described Above
We may use or disclose your protected health information pursuant to your written authorization for purposes other than treatment, payment or health care operations. You have the right to revoke a written authorization at any time as long as your revocation is provided to us in writing. If you revoke your written authorization, we will no longer use or disclose your protected health information for the purposes identified in the authorization. Your revocation will not be effective for uses and disclosures made in reliance on your prior authorization. Restrictions on disclosure of Protected Health Information (PHI) to a Health Plan We will abide by your written request to restrict disclosure of protected health information for services for which you will pay out-of-pocket in full. If you would like to request this restriction, please provide a written request and make advance arrangements with the health care companies to self-pay for the services provided.
These are notes made by a mental health professional documenting conversations during private counseling sessions or in joint or group therapy. Many uses or disclosures of psychotherapy notes require your authorization.
We will not use or disclose your protected health information for marketing purposes without your authorization. Moreover, if we will receive any financial remuneration from a third party in connection with marketing, we will tell you that in the authorization form.
We will not sell your protected health information to third parties without your authorization. Any such authorization will state that we will receive remuneration in the transaction.
USES OR DISCLOSURES PERMITTED OR REQUIRED BY LAW
Certain state and federal laws and regulations either require or permit us to make certain uses or disclosures of your protected health information without your permission. These uses or disclosures are generally made to meet public health reporting obligations or to ensure the health and safety of the public at large. The uses or disclosures which we may make pursuant to these laws and regulations include the following:
Public Health Activities We may use or disclose your protected health information to public health authorities that are authorized by law to receive and collect protected health information for the purpose of preventing or controlling disease, injury or disability.
Abuse, Neglect or Domestic Violence
We may notify the appropriate government authority if we believe an individual has been the victim of abuse, physical or financial, neglect, elder abuse, a crime, or domestic violence. Unless such disclosure is required by law (for example, to report a particular type of injury), we will only make this disclosure if you agree or in other limited circumstances when such disclosure is authorized by law.
Health Oversight Activities
We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.
If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute, but only if reasonable efforts have been made to notify you of the request or to obtain an order from the court protecting the information requested.
Worker’s compensation We may use or disclose your protected health information to worker’s compensation programs when your health condition arises out of a work-related illness or injury.
We may release certain health information to law enforcement authorities for law enforcement purposes, such as:
as required by law, including reporting certain wounds and physical injuries,
in response to a court order, subpoena, warrant, summons or similar process,
to identify or locate a suspect, fugitive, material witness or missing person
about the victim of a crime if we obtain the individual’s agreement or, under certain limited circumstances, if we are unable to obtain the individual’s agreement,
to alert authorities of a death we believe may be the result of criminal conduct,
information we believe is evidence of criminal conduct occurring on our premises, or
in emergency circumstances to report the suspicion of a crime against one of our patients including the location of the crime or the victim’s identity, or a description or location of the person who committed the crime.
We must comply with federal and state laws in making such disclosures for law enforcement purposes.
Following your death, we may disclose health information to a coroner or to a medical examiner as necessary for them to carry out their duties and to funeral directors as authorized by law. In addition, following your death, we may disclose health information to a personal representative (for example, the executor of your estate), and unless you have expressed a contrary preference, we may also release your health information to a family member or other person who acted as a personal representative or was involved in your care or payment for care before your death, if the health information is relevant to such person’s involvement in your care or payment for care. We are required to apply safeguards to protect your health information for 50 years following your death.
Coroners, Medical Examiners, or Funeral Directors We may use or disclose your protected health information to a coroner or medical examiner for the purpose of identifying a deceased individual or to determine the cause of death. We also may use or disclose your protected health information to a funeral director for the purpose of carrying out his/her necessary activities.
Organ, Eye or Tissue Donation
We may release health information to organ, eye or tissue procurement, transplantation or banking organizations or entities as necessary to facilitate organ, eye or tissue donation and transplantation.
We may use or disclose your protected health information for research purposes under certain limited circumstances. For example, you may have chosen to participate in a research study with a non-affiliated covered entity.
Threats to Health or Safety
Under certain circumstances, we may use or disclose your health information to prevent a serious and imminent threat to health and safety if we, in good faith, believe the use or disclosure is necessary to prevent or lessen the threat and the disclosure is to a person reasonably able to prevent or lessen the threat (including the target) or is necessary for law enforcement authorities to identify or apprehend an individual involved in a crime.
Specialized Government Functions
We may use and disclose your health information for national security and intelligence activities authorized by law or for protective services of the President. If you are a military member, we may disclose to military authorities under certain circumstances. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose to the institution, its agents or a law enforcement official, health information necessary for your health and the health and safety of other individuals.
Incidental Uses and Disclosures
There are certain incidental uses or disclosures of your information that occur while we are providing service to you or conducting our business. For example, the clinician may need to use your name to identify family members that may be in a waiting area. Other individuals waiting in the same area may hear your name called. We will make reasonable efforts to limit these incidental uses and disclosures.
Access to Health Information
As a resident/patient/client, or their legal representative if the primary is incapacitated, you may inspect and receive a copy of much of the health information we maintain about you, with some exceptions. You may ask for an electronic copy of that portion of your records that is created and maintained electronically. We will provide the information to you in the form and format you requested, assuming it is readily producible. If we cannot readily produce the record in the form and format you request, we will produce it another readable electronic form to which we agree. Please note the portion of your records created and maintained on paper may be provided in that format at the discretion of the entity. We may charge a cost-based fee for producing copies. If you direct us to forward your health information to another person, we will do so, provided your signed, written direction clearly designates the recipient and location for delivery. We may charge a fee for the costs of copying, mailing, and other supplies or work associated with your request. We will respond to your requests to exercise any of the above rights on a timely basis in accordance with our policies and as required by law.
Request for Restrictions
You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations or to persons involved in your care or payment for your care. We are not required to agree to your request, with one exception explained in the next paragraph, but we will let you know whether we have agreed to your request.
We are required to agree to your request that we not disclose certain health information to your health plan for payment or health care operations purposes if (1) you pay out-of-pocket in full for all expenses related to that service either at the time of service or within time-frames specified by our written policies and (2) the disclosure is not otherwise required by law. Such a restriction will only apply to records that relate solely to the service for which you have paid in full. If we later receive an authorization from you dated after the date of your requested restriction which authorizes us to disclose all of your records to your health plan, we will assume you have withdrawn your request for restriction.
Several different covered entities listed at the start of this Notice use this Notice, including the entities listed in Attachment A that are a single affiliated covered entity known as the Avamere Affiliated Covered Entity (or “Avamere ACE”). This Notice does not cover non Avamere ACE workforce members, such as your personal physician. You must make a separate request to each covered entity from whom you will receive services that are involved in your request for any type of restriction. Contact the Avamere ACE Privacy Officer at the contact information listed below if you have questions.
You may request that we amend certain health information that we keep in your records if you believe that it is incorrect or incomplete. We may require you to give a reason to support your request. We are not required to make all requested amendments, but will give each request careful consideration. If we deny your request, we will provide you with a written explanation of the reasons and your rights. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
was not created by any Avamere ACE entity,
is not part of the protected health information kept by or for our health care companies,
is not part of the information which you would be permitted to inspect and copy, or
is accurate and complete.
Accounting of Disclosures
You have the right to receive a list of certain disclosures of your health information made by us or our business associates. You must state a time period for your request, which may not be longer than six years. Your right to an accounting of disclosures does not include disclosures for treatment, payment or health care operations and certain other types of disclosures, for example, as part of a facility directory or disclosure in accordance with your authorization. Requests must be in writing. You may contact the Privacy Officer to obtain a form to request an accounting of disclosures.
You have the right to request that we communicate with you about your health information in a different way or at a different place. We will agree to your request if it is reasonable and specifies the alternate means or location to contact you.
Notice in the Case of Breach
You have the right to receive notice of an access, acquisition, use or disclosure of your health information that is not permitted by HIPAA, if such access, acquisition, use or disclosure compromises the security or privacy of your PHI (we refer to this as a breach). We will provide such notice to you without unreasonable delay but in no case later than 60 days after we discover the breach.
How to Exercise These Rights
All requests to exercise these rights must be in writing. We will follow company policies to handle requests and notify you of our decision or actions and your rights.
Contact the Privacy Officer at 503-570-3405 located at Avamere Health Services, LLC, 25117 SW Parkway, Wilsonville, Oregon 97070 for more information or to obtain request forms. To request a copy of your legal health record, please contact the medical records department of the treating affiliated entity to request a release form.
Complaints or Concerns
If you have concerns about any of our privacy practices or believe that your privacy rights have been violated, you may file a complaint with the Avamere ACE Privacy Officer using the contact information at the end of this Notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. You will not be penalized or retaliated against for filing a complaint.
Avamere ACE Privacy Officer
25117 SW Parkway, Suite B
Wilsonville, OR 97070