Medicare Coverage: A Case Study Heidi is a 72 year-old female who is hospitalized for 70-days after experiencing a stroke and further complications of a deep vein thrombosis of the leg and pulmonary embolus. Her current insurance includes Medicare Part A and B without Medicaid or a Medigap policy. While in the hospital she is treated by both a hospitalist and neurologist. Following her hospitalization stay, she is transferred to a skilled nursing facility (SNF) for rehabilitation. After a 30-day stay at the SNF, she is still unable to return home due to the severity of her disability. She transitions to a nursing home for custodial care, where she remains for the next 3-months. After this time passes, she becomes well enough to go home,
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“A patient-centered medical home provides patient-centered, comprehensive, and coordinated care that supports patient self care; offers superb access to care; and employs a systems-based approach to quality and safety (Taylor, Lake, Nysenbaum, Peterson, & Meyers, 2011).” After experiencing a medical emergency, the patient was initially hospitalized. Once stabilized to the point that she no longer needed hospitalization, she was transferred to a SNF for rehabilitation. Following rehab, arrangements were made amongst family members and a case manager to transition Heidi into a nursing home to assist with ADLs and IADLs because she was too severely disabled to return home. Upon significant improvement, Heidi was transitioned back home and had continued care with a home health agency providing physical therapy and a homemaker. All of these services were very well coordinated and supported Heidi’s transition to self care. A systems-based approach was employed that supported the quality and safety of her care. “The primary activity of a well-functioning medical neighborhood is delivery of coordinated care, which requires regular communication, collaboration, and shared decision-making across various actors in the system (Taylor et. al,
“A patient-centered medical home provides patient-centered, comprehensive, and coordinated care that supports patient self care; offers superb access to care; and employs a systems-based approach to quality and safety (Taylor, Lake, Nysenbaum, Peterson, & Meyers, 2011).” After experiencing a medical emergency, the patient was initially hospitalized. Once stabilized to the point that she no longer needed hospitalization, she was transferred to a SNF for rehabilitation. Following rehab, arrangements were made amongst family members and a case manager to transition Heidi into a nursing home to assist with ADLs and IADLs because she was too severely disabled to return home. Upon significant improvement, Heidi was transitioned back home and had continued care with a home health agency providing physical therapy and a homemaker. All of these services were very well coordinated and supported Heidi’s transition to self care. A systems-based approach was employed that supported the quality and safety of her care. “The primary activity of a well-functioning medical neighborhood is delivery of coordinated care, which requires regular communication, collaboration, and shared decision-making across various actors in the system (Taylor et. al,