|
Interdisciplinary
Continued Care (ICC) provides care that is goal oriented,
comprehensive and at an acuity level higher than can be provided
in a skilled nursing home setting. ICC is rendered immediately
after or in place of acute hospitalization to treat one or
more specific, active, complex medical conditions or to administer
one or more technically complex treatments in the context
of a person's underlying long-term conditions. Generally,
the type of care required does not depend heavily on high
technology monitoring or complex diagnostic procedures.
Interdisciplinary
Continued Care (ICC)
Mission/Goals
of Program
The
mission of the ICC program is to provide care that is goal
oriented, comprehensive and at an acuity level higher than
can be provided in a skilled nursing home setting, and is
rendered immediately after or in place of acute hospitalization
to treat one or more specific, active, complex medical conditions
or to administer one or more technically complex treatments
in the context of a person's underlying long-term conditions.
Generally, the type of care required does not depend heavily
on high technology monitoring or complex diagnostic procedures.
Scope
of Care
"Extended
but time-limited care to patients with complex medical, rehabilitation,
or behavioral problems that require comprehensive, outcome-based
interdisciplinary team administered care." (DVA Patient Care
Services Information Letter IL-11-97-001). The intensity of
care is higher than can be provided in a SNF, but not requiring
an acute care bed. These patients must have a completed medical
treatment plan in place for their primary diagnosis, with
potential for improvement in medical condition or function.
Programmatic improvements have included: 1)the development
of standard practice guidelines for wound care with weekly
interdisciplinary wound care rounds; 2)End of Life Care review
related to pain and symptom management, community hospice
referrals, advanced directives and living wills, and coordination
of follow up with oncologists or surgical subspecialists;
3)coordination to primary care- to prior care or the establishment
of new care based on changes in health care needs related
to illness; and instruction and follow up on complex in-home
management of chronic medical conditions, including use of
durable medical equipment or complex care issues related to
tube feedings, total parental nutrition, or wound care.
Types
& Ages of Patients Served
Patients
range in age from the 40's to 90's, with and estimated mean
in the 60's. Many of these patients have inadequate social
support systems or have been referred from remote areas, including
Loma Linda, Las Vegas, and Phoenix, as well as the greater
Los Angeles area.
Scope
and Complexity of Patient Needs
Specific
Admission Criteria for ICC Patients that have had an acute
illness, injury or surgery that have the potential for medical
and/or functional improvement, have minimal further diagnostic
requirements; AND one of the following conditions:
- Completion
of medical therapy that is too complex, requires close monitoring
(more than weekly), and/or requires input from subspecialists
than is possible in the NHCU.
- Radiation
Therapy for frail oncology (unable to go to XRT in a wheel
chair) patients or those s/p recent chemotherapy.
-
Complex wound care that requires active physical debridement.
-
Chronic mechanical ventilation
-
Behavior problems that have created recurrent hospitalization
or ER visits.
Exclusionary
Criteria include
- High
nursing acuity, such as need for frequent (more than q2h)
observation because of behavioral problems, safety problems,
elopement risk; or more specific acute nursing care such
as frequent vital signs or suctioning.
- IV
heparin
-
Multiple blood draws per day
-
Tuberculosis isolation
-
Incomplete Medical workup or lack of clear medical treatment
plan (see accompanying attachment regarding admission policy)
|
