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Interdisciplinary Continued Care (ICC)

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:

  1. 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.
  2. Radiation Therapy for frail oncology (unable to go to XRT in a wheel chair) patients or those s/p recent chemotherapy.
  3. Complex wound care that requires active physical debridement.
  4. Chronic mechanical ventilation
  5. Behavior problems that have created recurrent hospitalization or ER visits.

Exclusionary Criteria include

  1. 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.
  2. IV heparin
  3. Multiple blood draws per day
  4. Tuberculosis isolation
  5. Incomplete Medical workup or lack of clear medical treatment plan (see accompanying attachment regarding admission policy)

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Last Updated: March 24, 2005 -- Copyright 2000 GeroNet