Ukucela umngeni kwiSibhedlele esingakhuselekanga okanye ngaphambi kwexesha okanye ukukhutshwa kweRehab kuMntu oPhezulu¶

Izibhedlele kunye neendawo zabongikazi abanezakhono (SNFs) zisebenza phantsi koxinzelelo olukhulu lwemali kunye nomthamo webhedi ukunciphisa ubude besigulane sokuhlala. Iintsapho zisoloko zinikwa amaphepha okukhupha ngeeyure ezimbalwa zesaziso, naxa umntu omdala engekakwazi ukuma ngaphandle koncedo, uhlala ebhideke kakhulu, efuna amayeza emithanjeni, okanye engenamkhathaleli okhuselekileyo ekhaya. Ukuthatha ikhaya elikhulu elingazinzanga ngokwezonyango okanye elingasebenziyo kwisithuthi sakho kuba umphathi wetyala lesibhedlele uthi ixesha le-inshurensi liphelile ngoyena nobangela wokuwa kwentlekele, inyumoniya yokulangazelela, iimpazamo zamayeza, kunye nokufundwa kwegumbi likaxakeka kwiiyure ezingama-48.

Unamalungelo asemthethweni aseMelika, eUnited Kingdom, eKhanada, eOstreliya, nakwi-European Union ukumisa ukukhutshwa kwangaphambi kwexesha kwaye unyanzelise uphononongo oluzimeleyo lonyango phambi kokuba isigulana sishiye isakhiwo. Nje ukuba ukhuphe isithandwa sakho kwiingcango zesibhedlele kwaye usayine isishwankathelo sokukhutshwa, igunya lakho elisemthethweni kunye nokhuseleko lwe-inshurensi oluzenzekelayo luyaphela. Ngokugcina isigulane ebhedini kunye nokucela imimiselo yesibheno yokukhutshwa ngokusemthethweni kwindawo leyo, unyanzelisa indawo yokugcina unyango olupheleleyo ngelixa oogqirha bangaphandle baphonononga itshathi okanye ngelixa ukulungiswa kwezigulane ezikhuselekileyo zilungiselelwe.

Yenza oku ngoku¶

1. Yala ukusayina amaphepha okukhutshwa okanye ukuthutha isigulane ekhaya. Tshela umongikazi, ugqirha, kunye nomcwangcisi wokukhutshwa ngokuzola nangokucacileyo: "Oku kukhutshwa kucetywayo akukhuselekanga. Asinalo uqeqesho lwezonyango, amandla omzimba, okanye izixhobo zokugcina esi sigulana sikhuselekile ekhaya, kwaye asiyi kuzilanda namhlanje." Ukuba isigulana ngoku sijongene nengxaki yempilo esongela ubomi abasebenzi abangayihoyiyo, fowunela iQela leeMpendulo eziKhawulezileyo esibhedlele okanye utsalele umnxeba kwinombolo yakho yexesha likaxakeka (911 eUnited States naseKhanada, 112 kwi-European Union, 999 eUnited Kingdom) okanye ujonge amanani kaxakeka.
2. Funa isaziso esibhaliweyo samalungelo okubhenela ngokukhawuleza. EUnited States, sonke isigulana se-Medicare kunye ne-Medicare Advantage kufuneka sifumane ifom esemthethweni enesihloko esithi Umyalezo obalulekileyo ovela kwi-Medicare (iFomu CMS-10065) esibhedlele okanye *Isaziso se-Medicare Non-Coverage (iFom CMS-10123 phambi kokukhutshwa kwezakhono)
3. Fowunela i-arhente yezibheno ezimeleyo phambi komhla wokugqibela omiselwe ngokomthetho. EUnited States, tsalela umnxeba kuMbutho ojongene noMxhamli kunye noMbutho wokuPhuculwa koMgangatho weNkathalelo yoSapho (BFCC-QIO) eprintwe kwisaziso phambi kobusuku bobusuku bokukhutshwa esibhedlele (okanye emini emaqanda kusuku oluphambi kokuphela konyango lokubuyisela kwimeko yesiqhelo). EUnited Kingdom, qhagamshelana neeNgcebiso zezigulane kunye neNkonzo yoNxibelelwano (PALS) kunye neWard Matron; eKhanada, qhagamshelana noNozikhalazo weZigulana zeSibhedlele.
4. *Gxininisa kuvavanyo kwakhona lwe-Physical Therapy kunye ne-Occupational Therapy. Cela ugqirha okhoyo ukuba aodole ibhedi esecaleni kwePhysical Therapy (PT) kunye ne-Occupational Therapy (OT) yovavanyo olusebenzayo olubandakanya ukutshintshwa kokuhlala-ukuma, umgama wokuhamba, ukukhwela izitebhisi, kunye nokudluliselwa kwindlu yangasese. Ukuba i-PT okanye i-OT amaxwebhu ukuba isigulane sidinga uncedo lwabantu ababini okanye akakwazi ukusebenzisa izitebhisi zokungena ekhaya, ukukhutshwa kwekhaya kunqatshelwe ngeklinikhi.
5. Hlola ubume besigulana sokulaliswa (Isigulana esiLalelayo vs. Ukuqwalaselwa). Ukuba umzali wakho ukwisibhedlele saseUnited States phantsi kweTraditional Medicare, buza umphathi wetyala ukuba bahlelwa "njengesigulana" esisemthethweni okanye "Uqwalaselo Lwezigulana Ezingaphandle." Ukuba ziye zagcinwa phantsi kwesimo sokuQaphela iintsuku ezininzi, funa uphononongo olukhawulezileyo yikomiti yoHlolo lokuSetyenziswa kwesibhedlele ukuze kuguqulelwe ukuhlala kwiSigulana esiLalelayo ngaphambi kokuba sikhululwe ukuze i-Skilled Nursing Facility (SNF) iqale.
6. Faka izichaso zakho zokhuseleko kwirekhodi yezonyango esisigxina. Thumela umyalezo omfutshane, oyinyaniso nge-elektroniki yesigulana portal (efana ne-MyChart) okanye unike ileta ebhaliweyo kuMongikazi oCharge kunye noMphathi weCase edwelisa zonke izithintelo ezithile ezisebenzayo kunye nezonyango zokubuyela ekhaya.

flowchart TD
    A["Isibhedlele okanye i-rehab ibhengeza ukukhululwa okukufuphi komdala ongazinzanga"] --> B{"Ngaba umntu ophezulu unokutshintshela ngokukhuselekileyo, indlu yangasese, ukuginya, nokulawula ekhaya?"}
    B -->|"Ewe: Isiseko sibuyiselwe kwaye izixhobo zilungile"| C["Gqibezela ulungelelwaniso lwamayeza kunye neshedyuli yolandelelo lweentsuku ezi-7"]
    B -->|"Akhona:Akukhuselekanga ukubuyela ekhaya"| D["Ukwala ukusayina amaphepha okukhutshwa okanye ukuthutha isigulane"]
    D --> E{"Loluphi uhlobo lweziko kunye nenkqubo yezempilo?"}
    E -->|"Isibhedlele sase-US (i-Medicare okanye i-Medicare Advantage)"| F["Funa umyalezo obalulekileyo ovela kwi-Medicare (CMS-10065)"]
    E -->|"UMongikazi oFunekileyo wase-US / Rehab (SNF)"| G["Isaziso seMbango seMedicare Non-Coverage (CMS-10123)"]
    E -->|"I-UK NHS / Canada / Australia / I-Inshurensi yaBucala"| H["Ifayile yokubamba ngokusesikweni kunye ne-PALS, i-Ombudsman yezigulane, okanye uPhononongo lokuSebenzisa"]
    F --> I["Fowunela i-BFCC-QIO (i-Acentra okanye i-Livanta) ngaphambi kobusuku bobusuku bokukhutshwa"]
    G --> J["Fowunela i-BFCC-QIO emini emaqanda ngaphambi kokuphela kokhuseleko"]
    I --> K["Ukuhlala ngokuzenzekelayo kubangele: Isibhedlele asikwazi ukukhupha okanye ukukhupha i-pocket ngexesha lokuphonononga"]
    J --> K
    H --> L["Funa izitepsi ze-PT / OT kunye nophicotho lokudluliselwa kunye nenkomfa yokhathalelo lwezifundo ezininzi"]
    K --> L

Ukuqaphela xa isibhedlele okanye ukukhutshwa kwe-rehab kungakhuselekanga ngokwezonyango¶

Abacwangcisi bokukhutshwa kwezibhedlele bahlala bephatha uzinzo lwezonyango kuxilongo oluphambili lokwamkelwa njengemfuneko kuphela yokuthumela umntu omdala ekhaya. Ugqirha usenokuphawula ukuba inyumoniya yesigulana iyaphucuka kumayeza okubulala amayeza asetyenziswa emlonyeni okanye ukuba uqhaqho lwaso lotyando lubonakala lucocekile, ngoxa engayihoyi kwaphela into yokuba iintsuku ezintlanu zokulala ishiye isigulana esineminyaka engama-82 ubudala singakwazi ukuphakama kwindlu yangasese okanye sicoceke. I-delirium esibhedlele kunye nokudideka ngokukhawuleza.

Ngaphambi kokuba uvume naluphi na usuku lokukhutshwa, vavanya isigulane kwiinkalo ezintandathu zeklinikhi kunye nokusebenza kokhuseleko. Ukuba isigulana siyasilela nokuba enye yezi khrayitheriya kwaye iziko alilungiselelanga ukhathalelo lweeyure ezingama-24 kwiziko okanye ukonga okuqhubekekayo kobuchwephesha basekhaya, ukukhutshwa akukhuselekanga.

Ungasifaka njani isibheno sokukhutshwa ngoko nangoko kwisibhedlele saseMedicare (eUnited States)¶

EUnited States, umthetho womanyano (42 CFR iSigaba 405, iSubpart J) unika wonke umntu ofumana uncedo olukhuselwe yi-Original Medicare okanye isicwangciso sabucala se-Medicare Advantage ilungelo lophononongo olukhawulezileyo, oluzimeleyo lonyango phambi kokuba akhululwe kwisibhedlele esikwisibhedlele esingalaliswanga.

Inyathelo loku-1: Funa "Umyalezo obalulekileyo ovela kwi-Medicare" (iFomu CMS-10065)¶

Izibhedlele kufuneka zihambise isaziso sobumbano esinamaphepha amabini esinesihloko esithi Umyalezo oBalulekileyo ovela kwi-Medicare Malunga namaLungelo Akho (iFomu CMS-10065) kabini ngexesha lokuhlala kwesigulana ngasinye: phakathi kweentsuku ezi-2 zekhalenda zokungeniswa, kwaye kwakhona phakathi kwe-4 kunye ne-48 iiyure ngaphambi kokukhutshwa.

IFomu yokuSayina i-CMS-10065 ayithethi ithetha ukuba uyavuma ukuba isigulana sikulungele ukugoduka; ivuma nje ukuba ifunyenwe inombolo yefowuni yesibheno. Ukuba isibhedlele sikuxelela ngomlomo ukuba umzali wakho ukhutshwa namhlanje ngaphandle kokukunika ikopi yesibini yeFomu CMS-10065 edwelisa inombolo yefowuni ye-BFCC-QIO, xelela umphathi wecala: "Awuzange uhambise uMyalezo obalulekileyo wokugqibela osebenzayo ovela kwi-Medicare. Ngaphantsi kwemithetho ye-CMS, oku kukhutshwa akukwazi ukuqhubeka de kube isaziso esibhaliweyo sinikezelwe."

Inyathelo 2: Biza i-BFCC-QIO ngaphambi kobusuku bobusuku ngosuku lokukhutshwa¶

Iikhontrakthi zeMedicare kunye nemibutho ezimeleyo yokuphonononga ugqirha ebizwa ngokuthi ** Abaxhamli kunye neMibutho yoPhuculo lweNkathalelo yeNtsapho (BFCC-QIOs) ** ukujongana nezibheno zokukhutshwa ngokukhawuleza: ** I-Acentra Health ** kunye ne ** Livanta **. Inombolo ye-QIO yasimahla yelizwe lakho iprintwe kwiPhepha 1 leFom CMS-10065 (okanye ufowunele u-1-800-MEDICARE kwi-1-800-633-4227).

• Umhla wokuGqibela Ezinzulwini Zobusuku obuBalulekileyo: Tsalela umnxeba kwi-BFCC-QIO ngaphambi kobusuku bobusuku (11:59 PM) ngosuku olucwangcisiweyo lokukhutshwa kwaye phambi kokuba isigulana sishiye isakhiwo.
• 24/7 Ivoyisimeyili kunye ne-Intanethi yokuFayila ibala: Imigca yokuthatha ye-BFCC-QIO isebenza 24/7. Ukushiya i-voicemail okanye kwi-intanethi ngaphambi kobusuku kunye negama lesigulana, inombolo ye-Medicare, igama lesibhedlele, kunye nenombolo yakho yokufowunelwa ngokusemthethweni kutshixa isibheno ngexesha. Rekhoda isitampu sexesha kunye nenombolo yokuqinisekisa.

Inyathelo lesi-3: Qonda ukuhlala ngokuzenzekelayo kokukhutshwa kunye nokukhusela imali¶

Ukufakela isibheno kwangethuba phambi kobusuku bubangela ukuba kuhlale ukukhutshwa okuzenzekelayo: 1. Isibhedlele asinakunyanzela isigulana ukuba sihambe: Ibhedi epheleleyo yezigulane, ukhathalelo lokonga, kunye nonyango lwezonyango kufuneka luqhubeke ngexesha lokuphononongwa kwe-QIO. 2. I-Zero ngaphandle kwe-pocket bed liability ngexesha lesibheno: Isibhedlele asikwazi ukuhlawulisa isigulane ngaphandle kwepokotho ngeentsuku ezongezelelweyo ze-inpatient ngelixa oogqirha be-QIO baphonononga itshathi, **nokuba i-QIO ekugqibeleni iyasikhanyela isibheno sakho **. 3. Isaziso esineenkcukacha zokukhutshwa (CMS-10066): Wakuba wenze isibheno, isibhedlele kufuneka singenise isaziso esibhaliweyo emini emaqanda ngosuku olulandelayo esichaza izizathu ezithile zeklinikhi abakholelwa ukuba ukhathalelo oluqatha lwesibhedlele alusafuneki.

Inyathelo lesi-4: Yenza imeko yakho yeklinikhi ngokuthe ngqo kumbuyekezi we-QIO¶

Xa i-BFCC-QIO ikubiza kwakhona (ngaphakathi kwe-12 kwiiyure ze-24), chaza iinyani ezithile zeklinikhi kwitshathi ebonisa ukungazinzi kwezonyango okanye iimfuno zenguqu ezingakhuselekanga: - * "Isigulana senza i-acute hypoactive delirium kwiiyure ezingama-48 ezidlulileyo, sihlala singaphantsi kwesiseko sokuqonda, kunye nokukhohlela xa uginya ulwelo." - *"Unyango loMzimba olubhalwe izolo ukuba isigulane sifuna uncedo lwe-2-Mntu ukudlulisa kwaye akakwazi ukunyuka izinyuko ze-6 ekhaya labo." - * "Isigulana sitshintshe kwi-intravenous ukuya kumayeza omlomo kuphela kwiiyure ze-3 ezedlulileyo, kwaye ukuzinza kweeyure ze-24 akuzange kuqinisekiswe." * - "Isigulana sifuna ukudluliselwa kwi-Inpatient Skilled Nursing Facility (SNF), kwaye ulawulo lwetyala aluzange lukhusele ibhedi eyamkelekileyo."

Inyathelo lesi-5: Kwenzeka ntoni xa i-QIO ikhupha isigqibo sayo¶

I-BFCC-QIO kufuneka iphonononge iirekhodi zonyango kwaye ikhuphe isigqibo kwi-*24 iiyure ** yokufumana ifayile yesibhedlele. - Isibheno sivunyiwe: Isaziso sokukhutshwa siyekisiwe kwaye ukhuseleko lweMedicare luyaqhubeka de isigulane sizinze okanye sidluliselwe ngokukhuselekileyo. - Isibheno saliwe: Awunatyala kwanto ngeeyure ezingama-24 ukuya kwezingama-48 zophononongo. Ityala eliphuma epokothweni liqala ngo-12:00 emini ngosuku lwekhalenda EMVA kokuba i-QIO ikwazise ngokukhanyela. Ukufakela isibheno kusakhusela iiyure ezingama-36 ukuya kwezingama-48 zokulungiselela izixhobo zasekhaya okanye ukubekwa kwindawo yesiqhelo, kwaye kuvumeleke isicelo esikhawulezileyo **sokuQingqwa kweNqanaba lesi-2 kuKontraki oZimeleyo oQinisekisiweyo (QIC).

I-Medicare "Isimo sokuQaphela" ngokumelene ne-"Imo yeSigulane" somgibe¶

Ukothuka kwezemali rhoqo kubantu abadala eUnited States nguMthetho othi Medicare Three-Midnight Inpatient Rule kunye "Imeko Yokujongwa Kwezigulane Ezingalaliswayo." Umntu omdala unokufika ngenqwelo yezigulana, ahlale kwigumbi eliphezulu esibhedlele, afumane amayeza e-IV, aze ahlale ubusuku obune ngelixa echazwe kwikhompyutha njengeIsigulana esingaphandle simkelwa kwindawo yokuBekelwaIiNkonzoKunokuba zigcinwe.

Kutheni imeko yokuQaphela ivala iZiko loLondolozo lweZakhono (i-SNF) lokubuyisela kwimeko yesiqhelo¶

Ngaphantsi kweCandelo le-A leMedicare yeMveli, i-Medicare ihlawula kuphela i-post-hospital Skilled Nursing Facility (SNF) ukuvuselelwa ukuba isigulane samkelwa ngokusemthethweni njenge- **Isigulana esilaliswayo ubuncinane kwii-midnights ezintathu ezilandelelanayo ** (ngaphandle kweeyure zegumbi likaxakeka kunye ne-Observation midnights). Ukuchitha i-2 ezinzulwini zobusuku kwi-Observation kunye ne-1 ezinzulwini zobusuku njengeSigulana esilaliswayo sivelisa i-zero Traditional Medicare coverage ye-SNF rehab, ebeka iintsapho kwiimfuno zentlawulo yabucala ye-400 ukuya kwi-700 yeedola ngosuku.

flowchart TD
    A["Umntu omdala ubekwe ebhedini esibhedlele kwiwadi yezonyango"] --> B["Buza umongikazi okanye umphathi wetyala ngoSuku loku-1: Ngaba imeko yeSigulana esiLalelayo ngokusesikweni okanye uPhononongo lweSigulana esiNgaphandle?"]
    B -->|"Ubume bokuLala ngokusesikweni"| C["Bala ezinzulwini zobusuku ezilandelelanayo emva komyalelo wokungeniswa kwesigulana esisemthethweni"]
    B -->|"Ubume beSigulana esiNgaphandle"| D{"Ngaba isigulana sisesibhedlele ngaphezulu kweeyure ezingama-24?"}
    C --> E{"Ubuncinci ezinzulwini zobusuku ezi-3 zilandelelana?"}
    E -->|"Ewe"| F["Ufanelekile kuNyango lweMveli iNdawo yeZiko lokuBonga ngezakhono (SNF) rehab"]
    E -->|"Hayi"| G["Buza ugqirha kunye noPhononongo lokuSetyenziswa ukwandisa ukuhlala kwesigulana ukuba azinzanga ekliniki"]
    D -->|"Ewe: Ngaphezu kweeyure ezingama-24"| H["IFomu yeMbango yeNyanga (iSaziso sokuQophela iSigulana saseMedicare)"]
    H --> I["Cela uGqirha okhoyo ukuba aqhagamshelane noPhononongo lokuSetyenziswa ukuze aguqulele kwiSigulana esiLalelayo phantsi koMthetho weZibini ezinzulwini zobusuku"]
    I --> J{"Ngaba isigulana sine-Medicare Advantage okanye i-Original Medicare?"}
    J -->|"I-Medicare Advantage"| K["Jonga ukuba isicwangciso siyawurhoxisa umthetho weentsuku ezi-3 zesigulana esingaphakathi kwinethiwekhi ye-SNF rehab"]
    J -->|"I-Original Medicare"| L["Ifayile ebuyiselweyo okanye isibheno esikhawulezileyo phantsi kwemithetho ka-Alexander v. Azar ukuba igcinwe kuQwalaselo lweentsuku ezi-3+"]

Uphicothwa njani kwaye ucele umngeni kwimo yokuQaphela phambi kokuba umke esibhedlele¶

1. Buza umbuzo wemeko rhoqo kusasa: Qinisekisa yonke imihla kunye nogqirha okhoyo kunye nomphathi wemeko ukuba ngaba isigulana siphantsi komyalelo osemthethweni wezigulana ezilaliswayo okanye uPhononongo lweSigulana esingalaliswayo.
2. Qaphela ifom yeNYANGA (CMS-10495): Izibhedlele ezigcina isigulana se-Medicare sikwi-Observation ngaphezu kweeyure ezingama-24 kufuneka zizise Isaziso se-Medicare Outpatient Observation (NYANGA) kwiiyure ezingama-36.
3. ** Gcoba i-CMS ye-Two-Midnight Rule kunye noPhononongo lokuSetyenziswa:** Ngaphantsi kwe-CMS **I-Two-Midnight Rule , ukuba ugqirha ulindele ukuba isigulane sifune ukhathalelo lwesibhedlele ubuncinane kwii-midnights ezimbini, ukwamkelwa kwesigulana kufanelekile. Buza ** UGqirha oQondayo ** kunye ** UPhononongo lokuSebenzisa (i-UR) uMcebisi kaGqirha ngokukhawuleza ** IKhowudi yoMqathango 44 ukuphononongwa ** ukuguqula isimo sokuQaphela kwisigulana esisemthethweni ngaphambi kokukhutshwa.
4. Sebenzisa i-Alexander v. Azar (CMS-4204-F) Ilungelo lokuQaphela iSibheno: Abaxhamli beMedicare baphinde bahlelwa kwakhona ukusuka kwi-Inpatient ukuya kwi-Observation (okanye bagcinwe esibhedlele iintsuku ezi-3 + ngaphandle kweCandelo A le-SNF) banamalungelo olawulo lwesibheno nge-QIO.
5. Jonga i-Medicare Advantage 3-Day Waivers Rule: Ngaphezulu kwe-80 ipesenti yabucala I-Medicare Advantage (Icandelo C) iceba ukurhoxisa imfuneko yeentsuku ezi-3 zokuhlala kwesigulana kunye nokugunyazisa ukudluliselwa ngokuthe ngqo kwi-in-network SNF rehab.

Ukumisa ukukhutshwa kwangaphambi kwexesha kwiZiko lokuBonga ngezakhono (SNF) okanye iziko lokubuyisela¶

Ngokumalunga ne-** Usuku lwe-10 ukuya kuSuku lwe-21 ** kwi-Skilled Nursing Facility (SNF), iintsapho zivame ukuxelelwa: * "I-Medicare ihlawula kuphela iintsuku ze-20, okanye umzali wakho uye waxhamla kunyango lomzimba, ngoko ke ukhuseleko luphela kwiiyure ze-48." * Zombini amabango ahlala exoka phantsi komthetho we-federal Medicare.

Intsomi 1: "I-Medicare igubungela kuphela iintsuku ezingama-20 zokubuyela kwimeko yesiqhelo"¶

I-Medicare Icandelo A libandakanya **ukuya kwii-100 iintsuku ze-Skilled Nursing Facility care ngexesha ngalinye lenzuzo ** okoko nje isigulane sifuna ukonga abanezakhono mihla le okanye unyango lokubuyisela kwizakhono (PT, OT, okanye i-Speech Therapy ubuncinane iintsuku ezi-5 ngeveki). Iintsuku ezi-1 ukuya kwe-20 zithwala i-copay ye-$ 0, ngelixa ii-Days 21 ukuya kwi-100 zithwala i-coinsurance yomthetho yemihla ngemihla (ehlanganiswe ngokupheleleyo yi-Medigap Plans G okanye F, okanye i-Medicaid). Ngenxa yokuba imbuyekezo iyancipha emva kweeveki ezintathu, amaziko adla ngokucinezela iintsapho ukuba ziphume kwangethuba nangona kukho izakhono eziqhubekayo.

Intsomi yesi-2: "Sikhulula umzali wakho ngenxa yokuba ethe tye" (The Jimmo v. Sebelius Settlement)¶

Amaziko okubuyisela kwimeko yesiqhelo ahlala ephelisa ukhuseleko ngempazamo xa isigulana esinestroke, isifo sikaParkinson, okanye isifo sengqondo esixhalabisayo siyeka ukubonisa impumelelo ekhawulezileyo kumgama wokuhamba. Ngaphantsi kwe-federal class-action settlement Jimmo v. Sebelius (Medicare Benefit Policy Manual, Isahluko 8), **I-Medicare SNF kunye ne-Home Health coverage AKUKHO kuxhomekeka kwisigulane sokuphucula **.

Ufakwa njani isibheno kwiZiko leeNursing ezinezakhono ezisikiweyo (NOMNC Form CMS-10123)¶

1. Funa iSaziso se-Medicare Non-Caverage (NOMNC, Form CMS-10123): I-SNF mayizise le fom ibhaliweyo ubuncinane beentsuku ezi-2 zekhalenda (iiyure ezingama-48) phambi kokuba kuphele i-Medicare coverage.
2. Fowunela i-BFCC-QIO ngentsimbi ye-12:00 EMINI kusuku oluphambi kokuphela kokhuseleko: Ngokungafaniyo nezibheno zasesibhedlele (ezinzulwini zobusuku ngosuku lokukhutshwa), kwiZiko le-Skilled Nursing Facility kufuneka ufowunele inombolo ye-BFCC-QIO kwi-NOMNC ngo-12:00 emini ngosuku lwekhalenda PHAMBI kokuphela konyango.
3. Funa iNkcazelo eNgcacisiweyo ye-Non-Coverage (DENC, Form CMS-10124): Nje ukuba ufake isibheno, isibonelelo kufuneka sihambise i-DENC ebhaliweyo echaza izizathu ezichanekileyo zeklinikhi kunye nezandla zokupheliswa.
4. Cela iNqanaba lesi-2 lokuPhonononga kwakhona kunye noncedo lwe-Ombudsman ukuba luyimfuneko: Ukuba isibheno sokuqala se-QIO kwi-SNF sikhatyiwe, khawuleza ucele Iiyure ezingama-72 zeNqanaba lokuPhononongwa kwakhona kweNqanaba lesi-2 kwiNkontraka eZimeleyo eQinisekisiweyo (QIC) kwaye uqhagamshelane ne-Ixesha elide i-Ombudsman yoNonophelo kunye ne-SHIP nabacebisi. Ukuba ikhaya labalupheleyo lizama ukukhupha umhlali ngokumthumela kwi-ER kunye nokwala ukubuyiselwa ("ukulahlwa esibhedlele"), landela isikhokelo sethu ukuxhatshazwa kwikhaya labongikazi, ukungahoywa, kunye nokugxothwa ngokungekho mthethweni.

Ukhuseleko lokukhutshwa kwamanye amazwe: iUnited Kingdom, Canada, Australia, kunye ne-EU¶

Yonke inkqubo yezempilo yoluntu engundoqo inezikhuselo ezisemthethweni ezithintela izibhedlele ekukhupheni abantu abadala abaxhomekeke kubo ngaphandle kwesicwangciso sokhathalelo esiqinisekisiweyo.

I-United Kingdom (i-NHS): I-PALS, ukukhutshwa kuVavanyo, kunye ne-NHS eqhubekayo yezempilo (CHC)¶

Ngaphantsi kwe-NHS yaseNgilani ye-Hospital Discharge kunye neSikhokelo seNkxaso yoLuntu * kunye ne-Care Act 2014 *, ii-NHS trusts zisebenzisa ezine ** Ukukhutshwa ukuvavanya (D2A) ** iindlela: ** Indlela ye-0 ** (ukukhutshwa okulula ngaphandle kweemfuno ezintsha), ** Indlela ye-1 ** (ikhaya kunye ne-reablement yoluntu 4 * , * i-intermedia ye-2) ukubuyisela kwisimo sangaphambili), kunye Indlela 3 (isigxina seeyure ezingama-24 zokhathalelo lokonga).

Ukuba iwadi izama ukukhulula umntu omdala obuthathaka kwiNdlela 0 okanye iNdlela yoku-1 phambi kokuba abasebenzi bokhathalelo bacwangciselwe ukutyelela: 1. Qhagamshelana ** noMphathi weWadi (uDade/uMongikazi weTyala)** kunye neNgcebiso yeSigulana kunye neNkonzo yoNxibelelwano (PALS) yesibhedlele ngokukhawuleza. 2. Yitsho ngokubhaliweyo: * "Oku kukukhutshwa okungakhuselekanga. Ngaphantsi koMthetho wokuNakekela i-2014 kunye ne-NHS Discharge Guidance, sifuna uvavanyo lwe-multi-disciplinary for Pathway 2 ukunakekelwa kwebhedi ephakathi, i-NHS Continuing Healthcare (CHC) Uluhlu lokuHlola ngaphambi kokukhutshwa, kunye noVavanyo lwe-Carer's Assessment ayinakuqinisekisa ukuba i-2 yentsapho inika i-2. "

Ukunyanzelisa uMthetho we-CARE: Amalungelo akho omthetho karhulumente njengomkhathaleli wosapho¶

Ngaphezulu kwe-44 yamazwe ase-US kunye nemimandla yenze i-CARE (Caregier Cebisa, Rekhoda, Yenza) Act*. Ngaphantsi koMthetho we-CARE, izibhedlele kufuneka zenze imisebenzi emithathu ngaphambi kokuba zikhuphe isigulana kwikhaya labucala: 1. Rekhoda uMkhathaleli woSapho: Nika isigulana ithuba lokwamkelwa ukuba sikhethe umntu okhathalela usapho kwitshati. 2. Yazisa Phambi Kokukhutshelwa okanye UkuTshintshela: Yazisa umkhathaleli ochongiweyo ngokukhawuleza ukuba umyalelo wokukhutshwa ubhaliwe naphambi kokuba uphume. 3. Bonelela ngokuPhila, uQeqesho oluSebenzayo lweMisebenzi yezoNyango: Ukubonelela ngomboniso ophilayo kunye nomyalelo wolwimi olucacileyo kuyo yonke imisebenzi yezonyango yasekhaya, kubandakanywa ukhathalelo lwenxeba elingenazintsholongwane, iinaliti ezingaphantsi kwesikhumba (ezifana ne-insulin okanye i-enoxaparin), ukutyisa ityhubhu, ioksijini yasekhaya kunye noomatshini bokufunxa, kunye nokhuseleko lwebhedi ukuya kwisitulo esinamavili okanye ukuhanjiswa kweHoyer.

Usetyenziswa njani uMthetho we-CARE ukumisa ukukhutshwa kwangaphambi kwexesha: Ukuba umongikazi ukunika iisirinji, ingxowa yecatheter, okanye i-gauze yamanxeba ngaphandle koqeqesho lokwenziwa ngezandla, wala ukusayina. Yithi: * "Ngaphantsi koMthetho we-CARE wombuso wethu, esi sibhedlele kufuneka sinikezele ngomyalelo ophilayo kwaye siqinisekise ukuba umnakekeli wentsapho unako ngokomzimba ukwenza yonke imisebenzi yezonyango kunye nokuphakamisa ngaphambi kokukhutshwa. Akukho mntu ekhaya unokuphakamisa isigulane ngokukhuselekileyo. Nceda ubhale phantsi ukuba imfuneko ye-CARE Act ayizange ifikelelwe. "*

Iincwadi zeempendulo zegama-negama kwiintlanganiso zasesibhedlele ezinoxinzelelo oluphezulu¶

Abaphathi beemeko zesibhedlele ngamanye amaxesha bathi "I-Medicare iya kuyeka ukuhlawula kwaye uya kuba netyala le-3,000 yeedola ngosuku," okanye "Ukuba awumlandeli umzali wakho nge-3:00 PM, siya kuxela ukulahlwa kwabantu abadala."

Yazi inyani yomthetho: ukwala ukuthatha isigulana kwisibhedlele esinelayisensi yeeyure ezingama-24 okanye indawo yokonga ngenxa yokuba ungenamandla, uqeqesho lwezonyango, okanye indawo ekhuselekileyo yokusinyamekela ekhaya AKUKHO ukulahlwa kwabantu abadala. Ngaphakathi esibhedlele, isigulana siphantsi komsebenzi osemthethweni wokhathalelo lweekliniki ezinelayisensi. Ngokuchaseneyo noko, ukuthatha ibhedi okanye ikhaya labadala elinezithukuthezi limsa kwindlu engakhuselekanga apho bawela khona kunokuqalisa uphando lokungahoywa kweeNkonzo zoKhuseleko lwaBadala (APS).

I-Script 1: Xa umcwangcisi wokukhupha uthi "Ugqirha ubhale umyalelo wokukhutshwa kwe-2: 00 PM namhlanje"¶

"Umzali wam akakho kwisiseko sabo esisebenzayo okanye esisengqondweni kwaye akakwazi ukudlulisela ngokukhuselekileyo kwindlu yangasese okanye ukunyuka izitepsi kwindlu yabo. Akukho mntu ekhaya okwaziyo ukuwaphakamisa ngokwasemzimbeni. Siyakuchasa ngokusemthethweni oku kukhutshwa njengokungakhuselekanga. Nceda undinike uMyalezo oBalulekileyo ovela kwi-Medicare (iFomu CMS-10065) ngoku ukuze ndikwazi ukubiza i-BFCC-Qchacha ye-BFCC kunye nephepha lokubhenela iphepha le-expedited. Unyango loNyango lokuphonononga kwakhona ukhuseleko lokudluliselwa."

Iscript 2: Umyalezo obhaliweyo oza kuncamatheliswa kwi-portal yesigulana sombane (MyChart)¶

"Ku: UGqirha, uMongikazi, kunye noLawulo lweCase / ukuSebenziswa kwakhona. Re: [Igama lesigulana, i-DOB, iGumbi]. Nceda ufake eli nqaku kwirekhodi yezonyango esisigxina. Intsapho yethu yazisa ngokusesikweni iqela lokunyamekela ukuba ukukhutshwa kwekhaya elicetywayo [Umhla] kufuna ukungakhuselekanga kwezonyango. Ngaphambi kwesi sigulo, [Igama loMgulane ngokuzimeleyo laliyiyo]. Uncedo lwabantu ababini lokuma, lunokudideka okukhulu, kwaye alunakukwazi ukulawula amayeza okanye indlu yangasese yedwa Akukho mntu unonophela ekhaya onokuphakamisa [iGama lesigulana] okanye anike iliso leeyure ezingama-24, kwaye izixhobo zonyango ezihlala ixesha elide azizange zihanjiswe ngokukhawuleza BFCC-QIO (Isiqinisekiso #[Inombolo])."

I-Script 3: Xa i-Skilled Nursing Facility (SNF) ithi "Umzali wakho uye waxhamla kunyango lomzimba"¶

"Nceda unikeze iSaziso esibhaliweyo seMedicare Non-Coverage (NOMNC, Form CMS-10123) ngokukhawuleza. Ngaphantsi kwe-federal Jimmo v. Sebelius settlement kunye neSahluko 8 se-Medicare Benefit Policy Manual, i-Medicare Part A I-SNF coverage ayifuni ukuphuculwa okuqhubekayo. Unyango lwezakhono oluyimfuneko kunye nokukhusela ukunakekelwa komzali kusekho ukugcinwa kwemihla ngemihla. Unyango lomzimba olunezakhono kunye nokubeka iliso lokonga ukunqanda ukuwa kunye neekhontrakthi, kwaye sifaka isibheno esikhawulezileyo kwi-BFCC-QIO ngaphambi kwemini ngomso."

Yintoni omawuyenze PHAMBI kokuba wamkele ukukhutshwa okusemthethweni¶

Sakuba isigulana sizinzile ngokwezonyango okanye utshintshelo olukhuselekileyo lwe-rehab okanye isicwangciso sokhathalelo lwekhaya sigqityiwe, gqibezela oku Iingongoma eziHlanu zoPhicotho lokuPhuma ngokuKhuselekileyo phambi kokuba uhambe:

• 1. Ulungelelwaniso lweMiyezo yoMda ngomgca ("uPhicotho lweBag eBrown"): Hlala phantsi nonesi okhuphayo okanye usokhemisti kwaye uphonononge onke amayeza asekhaya ecaleni kwawo onke amayeza kagqirha amatsha, uqinisekisa ngokubhala: Qhubeka ngedosi enye, Shintsha ithamo, Yeka ngokusisigxina, okanye Qalisa amayeza amatsha.
• 2. "Amayeza Esandleni" Ngaphambi kokuba Uhambe: Buza ikhemesti yesibhedlele yangaphakathi ("Inkqubo yeeMedi-to-Beds") ukuba igcwalise kwaye ihambise yonke imigqaliselo emitsha ecaleni kwebhedi phambi kokuba uhambe ukuze uqinisekise ugunyaziso lwangaphambili lwe-inshurensi kunye neekopi kwangoko.
• 3. IsiXhobo sezoNyango esiLungileyo (DME) ngokwaseMzimbeni Ngaphakathi eKhaya: Qinisekisa ukuba nasiphi na i-odolo yokuhamba, ibhedi esecaleni kwebhedi, isitulo seshawari, ibhedi yasesibhedlele, ilifti yeHoyer, okanye isigxininisi seoksijini sele singaphakathi endlwini phambi kokuba uphume. Kwizigulane ezixhomekeke kwi-oxygen, hlaziya Ukulungiswa kokuphela kombane kwi-oxygen concentrators, ii-ventilators, kunye ne-CPAP.
• 4. Igama le-Arhente yeMpilo yaseKhaya eBhaliweyo, iNombolo yeFowuni, kunye noMhla wokuTyelwa kokuQala: Fumana igama elichanekileyo le-Arhente yeMpilo yaseKhaya eyamkelekileyo, inombolo yabo yefowuni yeeyure ezingama-24, kunye nokuqinisekisa ukuba utyelelo lukamongikazi Ukuqala koNonophelo (SOC) lucwangciswe kwiiyure ezingama-24 ukuya kwezingama-48.
• 5. Inombolo ye-Callback ye-Red-Fleg kunye ne-7-Day yokuFumana i-Appointment: Fumana inombolo ye-24 yeyure yeklinikhi callback yeqela elikhuphayo, eprintiweyo isiShwankathelo sokukhutshwa, kunye nedinga lokulandelela elicwangcisiweyo phakathi kwe- **5 kwiintsuku ze-7 **. Ukuba umntu omthandayo uwela ekhaya, landela isikhokelo sethu abantu abadala bawela ukuchacha xa bengakwazi ukuma.

Imibuzo edla ngokubuzwa¶

Ngaba isibhedlele singabiza amapolisa okanye ndihlawuliswe ngokulahla umdala ukuba ndiyala ukuphuthuma umzali wam ongakhuselekanga ukuba eze ekhaya?¶

Hayi, ukwala ukuthatha isigulana esingazinzanga ngokwezonyango okanye esingashukumiyo kwisibhedlele esinelayisensi yeeyure ezingama-24 okanye indawo yokonga abantu abanezakhono kuba awukwazi ukubanyamekela ngokukhuselekileyo ekhaya akuthethi ukulahlwa kwabantu abadala. Ngaphakathi esibhedlele, isigulana sikwimeko yonyango ekhuselekileyo phantsi komsebenzi osemthethweni wokhathalelo lweekliniki ezinelayisenisi, ngelixa ukuthatha umntu oxhomekeke kwikhaya elixhomekeke kwindawo engakhuselekanga ngaphandle kokuphakamisa uncedo kubabeka esichengeni sokwenzakala kakhulu. Zola, chaza ngokubhala ukuba uhlala ubandakanyeka kwisicwangciso sokhathalelo lwabo, kwaye uchaze ukuba usebenzisa ilungelo lakho elisemthethweni lokubhena ngokukhutshwa okungakhuselekanga de kube kwenziwe amalungiselelo okubuyisela kwisimo sangaphambili okanye ukhathalelo lwasekhaya.

What happens if I miss the midnight deadline on the day of hospital discharge to call the Medicare QIO?¶

If you miss the midnight deadline on the scheduled day of discharge (or the 12:00 noon day-before deadline in a Skilled Nursing Facility) but the patient is still physically inside the facility, call the BFCC-QIO immediately anyway. Under federal Medicare regulations, the QIO will still accept a late appeal from an inpatient and conduct an independent medical review within 2 calendar days, although you lose automatic financial liability protection for the days while the late review is pending unless the QIO rules in your favor.

Ngaba umzali wam unamalungelo e-Medicare okukhupha isibheno ukuba banesicwangciso sabucala se-Medicare Advantage endaweni ye-Original Medicare?¶

Yes, every beneficiary enrolled in a private Medicare Advantage (Part C) plan has the exact same federal statutory right to receive the Important Message from Medicare (in a hospital) or the Notice of Medicare Non-Coverage (in a skilled nursing facility) and to file an immediate, independent discharge appeal with the regional BFCC-QIO (Acentra Health or Livanta). Filing with the BFCC-QIO triggers the same automatic stay of discharge while independent QIO physicians review the medical record.

How do I get a hospital to change my parent from "Outpatient Observation" status to "Inpatient" status before they leave?¶

Ask to speak directly with the Attending Physician and the Hospital Utilization Review (UR) Physician Advisor while your parent is still in the hospital bed. Point out that your parent has crossed or is expected to cross two midnights requiring hospital-level care under the CMS Two-Midnight Rule, and request a formal Condition Code 44 review to convert their status from Outpatient Observation to formal Inpatient prior to discharge, or check whether their Medicare Advantage plan waives the 3-day inpatient rule for Skilled Nursing Facility rehab.

Imithombo ijongiwe¶

• Centers for Medicare and Medicaid Services (CMS, United States): Medicare Claims Processing Manual, Chapter 30: Financial Liability Protections, Hospital Discharge Appeal Notices (Form CMS-10065), and Skilled Nursing Facility Fast-Track Appeals (NOMNC Form CMS-10123).
• Centers for Medicare and Medicaid Services (CMS, United States): Jimmo v. Sebelius Settlement Agreement Fact Sheet and Medicare Benefit Policy Manual Chapter 8 (Maintenance Coverage Standard).
• Centers for Medicare and Medicaid Services (CMS, United States): Medicare Appeals of Hospital Reclassifications from Inpatient to Outpatient Observation Status (CMS-4204-F / Alexander v. Azar).
• Department of Health and Social Care and NHS England (United Kingdom): Hospital Discharge and Community Support Guidance (Discharge to Assess Pathways 0 to 3 and Care Act 2014 Statutory Duties).
• AARP Public Policy Institute (United States): The CARE (Caregiver Advise, Record, Enable) Act Statutory Implementation Standards.

Izikhokelo ezinxulumeneyo¶

• I-delirium yesibhedlele, ukudideka ngequbuliso, kunye nokuthethelelwa okuphezulu
• Nursing home abuse, neglect, and illegal eviction
• Abantu abadala bawela ukuchacha xa bengakwazi ukuma
• Power outage for oxygen concentrators, ventilators, and CPAP
• Iinombolo zikaxakeka zehlabathi