optimizing the guardianship process at dartmouth ...

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AT DARTMOUTH-HITCHCOCK MEDICAL CENTER: A QUALITY .... Suresh, MD, for review and assistance. Tracie Anne Caller, MD, for review and assistance.
OPTIMIZING THE GUARDIANSHIP PROCESS AT DARTMOUTH-HITCHCOCK MEDICAL CENTER: A QUALITY IMPROVEMENT COLLABORATIVE

Jasper James “JJ” Chen, MD, MBA, MSc Michele A. Blanchard, MSW Christine J. Finn, MD Karen A. Homa, PhD William J. Nugent, MD

 What is guardianship?  A state-specific, legal arrangement whereby one person has the legal duty to care for another

 When is guardianship needed?  Any incapacitated patient who lacks a Durable Power of Attorney (DPOA) for Health Care Guardianship is a complex process involving multiple persons & disciplines

MEDICAL TEAM

COURT SYSTEM

SOCIAL WORK

CARE

MANAGEMENT

PATIENT

 A guardianship tale: – 77 y.o.f. /w multiple comorbidities had unwitnessed fall and was admitted to DHMC via ED – Within 48 hours, need for guardianship was discussed by social workers – Psych eval 1 day later: she had the capacity to accept SNF – DPOA assignment attempted within 3 days of admission but patient wanted her deceased parents named as DPOA – Psych was thus re-consulted and found her not to have capacity to refuse SNF placement – Guardianship hearing and incompetency ruling within 3 weeks – Discharge occurred a week later

 Not reflective of the “right care” at the “right place” at the “right time” by “the right people”  Costs of delays in guardianship assignment:  Delay in hospital discharge  Risk of healthcare associated infections  Postponement of post-hospital rehabilitation  Ineffective bed utilization  Unnecessary hospital costs  Number of guardianship cases has steadily increased: 1995

2000

2-3 GUARDIANSHIP CASES/YEAR

2005

2010

2012

12 GUARDIANSHIP CASES/YEAR

Objective To improve the guardianship process at Dartmouth-Hitchcock Medical Center (DHMC), to avoid preventable discharge delays and unnecessary hospital days

Methods  A multi-disciplinary quality improvement workgroup was formed in September 2011 Patient & Family Relations Care Management

Social Work

• Monthly meetings • Mapped the guardianship process

Guardianship Quality Improvement Workgroup

Psychiatry

Preventive Medicine

Physical Medicine & Rehabilitation

Ethics Risk Management

• Analyzed for causes of delays in the process • Developed interventions

Interventions 1)

Creation of Standardized Operating Procedures for social workers’ roles and work flow.

2)

Creation of Monitoring Pathway to capture contextual, clinical, and logistic factors.  Data stored in a shared, secure virtual folder viewable by all process members.

3)

Improved Communication between DHMC and probate courts to expedite guardianship petition processing.

Outcome Assessment Methodology  Statistical process control (SPC) charts were used to ascertain reductions in length of hospital stay. 

Analyzed consecutive guardianship patients over 2 years (4/1/2011-4/1/2013).

 Cost savings were conservatively estimated. 

Average minimum charge per day at DHMC ($1,765) multiplied by the number of hospital days saved.



Savings further discounted by an average of DHMC’s cost-to-charge ratios.

Results Length of Stay in Days for Consecutive Guardianship Patients at DHMC from 4/1/2011 to 4/1/2013 Guardianship Team Monthly Meetings Initiated Standardization of SW Roles and Workflows Began Monitoring Pathway Started

Length of Stay in Days

Communication & Coordination with Local Probate Courts Improved

2011

1

2 3 4

5 6 7

2012

2013

8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Patient Number

Results  23 guardianship patients over 2 years  Mean length of stay decreased by 21 days (statistically significant)  The shorter hospitalizations of the most recent 11 patients: = 230 hospital days saved = ~$400,000 saved on hospital bed costs

Implications The actual costs saved are likely higher!  Opportunity costs for bed availability: revenue-generating procedures or treatments.  Reduced nosocomial infection rates.

The valuable resource of a tertiary referral hospital bed may be more appropriately utilized by patients with acute medical needs.

Summary  A multidisciplinary team implemented interventions to standardize the work flow of social workers and improve relationships with probate courts.  This has decreased guardianship petition processing times and has significantly reduced length of hospitalizations.

Acknowledgements  Members of the DHMC Guardianship Team: Christine J. Finn, MD Debra J. Cofell, RN James F. Gregoire

Michele Blanchard, MSW Debra A. Fournier, APRN Margaret L. Plunkett, RN

Yoni Stevens, MSW

Nancy Trottier, MSW

 Leadership Preventive Medicine Team: William J. Nugent, MD, FACS, LPMR Coach Karen A. Homa, PhD, Improvement Specialist Gautham K. Suresh, MD, for review and assistance. Tracie Anne Caller, MD, for review and assistance.

Jasper James “JJ” Chen, a psychiatry and leadership preventive medicine resident at Dartmouth-Hitchcock Medical Center at home in Grantham , New Hampshire with Romanza “Romi”, his nine month-old Belgian Tervuren. (Valley News - Sarah Priestap)

Appendices • I: Calculation of Cost Savings Using Charge-to-Cost Conversion and Addition of Minimum Daily Technical and Professional Charges at DHMC • II: Are we really seeing any “bottom-line” cost-savings as a result of our quality improvement endeavors? • III: The real significance of our quality improvement efforts: Improving patient outcomes, improving scarce resource allocation, and providing opportunities for other patients to utilize DHMC’s resources • IV: Guardianship Cases Excluded From Our Analysis • V: Standardized Workflows of Social Workers—New Hampshire and Vermont Processes • VI: Guardianship Process Monitoring Sheets • VII: Justification of Inclusion of Cases

Appendix I:Calculation of Cost Savings • The minimum daily charge at DHMC is comprised of: – 1) a technical charge (on which hospital unit the patient physically resides); plus – 2) a professional charge(s) (which service(s) is (are) rounding on the patient). • For example: A patient on the Neurology Ward (5 West) is charged: – $1,587 for technical charges, which costs DHMC $1,362, and has a costto-charge ratio of 0.86. – $178 for professional charges, which costs DHMC $82, and has a costto-charge ratio of 0.46. – Any additional consulting service(s) may incur further professional charges.

• Calculation of Cost Savings in Cost Accounting Methodology requires conversion of charges to costs using specified cost-to-charge ratios.

DHMC Technical Cost-to-Charge Ratios • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Charge Description / Unit Dly Rm Ch-Sr-Ed Hold Dly Rm Chg Pr 2E Psych Care Dly Rm Chg Sr 2W Psych Care Dly Rm Chg Pr Flex Team Unit Dly Rm Chg Sr Flex Team Unit Dly Rm Chg-Pr-Iccu-4E Dly Rm Chg-Pm-Iccu-4E Dly Rm Chg-Sr-Iccu-4E Dly Rm Chg Pr Ssu Same Day Dly Rm Chg Sr Ssu Same Day Dly Rm Chg-Pr-Neuro-5W Dly Rm Chg-Pm-Neuro-5W Dly Rm Chg-Neuro-5W Dly Rm Chg-Pr-Mho-1W Dly Rm Chg-Pm-Mho-1W Dly Rm Chg-Sr-Mho-1W Dly Rm Chg-Pr-Surg Spec-3Wst Dly Rm Chg-Pm-Surg Spec-3Wst Dly Rm Chg-Sr-Surg Spec-3Wst Dly Rm Chg-Pr-Hscu Dly Rm Chg-Pm-Hscu Dly Rm Chg-Sr-Hscu Dly Rm Chg-Pr-Med/Derm-1E Dly Rm Chg-Pm-Med/Derm-1E Dly Rm Chg-Sr-Med/Derm-1E Dly Rm Chg Pr 3E Med Spec Dly Rm Chg Pm 3E Med Spec Dly Rm Chg Sr 3E Med Spec Dly Rm Chg-Pr-Nscu Dly Rm Chg-Sr-Nscu Dly Rm Chg-Pr-Surgery-4W Dly Rm Chg-Pm-Surgery-4W Dly Rm Chg-Sr-Surgery-4W Dly Rm Chg Pr Surgery 2W Dly Rm Chg Pm Surgery 2W Dly Rm Chg Sr Surgery 2W

Charge per day 1,587 1,978 1,978 1,587 1,587 2,038 2,038 2,038 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587 1,587

Total Cost per day 2,425 1,273 1,273 1,417 1,417 1,291 1,291 1,291 1,254 1,254 1,362 1,362 1,362 1,366 1,366 1,366 1,287 1,287 1,287 1,383 1,383 1,383 1,295 1,295 1,295 1,295 1,295 1,295 1,541 1,541 1,279 1,279 1,279 1,407 1,407 1,407

SOURCE: DHMC Cost Accountant Miranda M. Handley

Cost to Charge Ratio 1.527909263 0.643574317 0.643572801 0.89263012 0.892626339 0.633439647 0.633441119 0.633441119 0.79031569 0.79031569 0.858099559 0.858100189 0.858099559 0.860672968 0.860672338 0.860671708 0.810806553 0.810807183 0.810805293 0.871565217 0.871565217 0.871566478 0.815982987 0.815977316 0.815983617 0.815982987 0.815974795 0.815983617 0.971034026 0.971039067 0.805639572 0.805640832 0.805639572 0.886412098 0.886412728 0.886410838

DHMC Professional Cost-to-Charge Ratios • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

PROFESSIONAL SERVICE Charge Amount ANESTHESIOLOGY 178 DERMATOLOGY 178 OTOLARYNGOLOGY 178 OPHTHALMOLOGY 178 NEUROSURGERY 178 OBSTETRICS & GYNECOLOGY 178 PLASTIC SURGERY 178 PEDIATRICS 178 GENERAL SURGERY 178 UROLOGY 178 DIAGNOSTIC RADIOLOGY 178 CARDIOLOGY 178 NEUROLOGY 178 DHC - RADIATION ONCOLOGY 178 GENERAL INTERNAL MEDICINE 178 HEMATOLOGY/ONCOLOGY 178 PULMONARY 178 INFECTIOUS DISEASE 178 HYPERTENSION 178 ENDOCRINOLOGY 178 RHEUMATOLOGY 178 GASTROENTEROLOGY 178 VASCULAR SURGERY 178 NEONATOLOGY 178 HIGH RISK - OB/GYN 178 GENETICS 178 PEDIATRIC SURGERY 178 PEDIATRICS CARDIOLOGY 178 PEDIATRICS HEM/ONC 178 ALLERGY & CLINICAL IMMUNOLOGY178 CHILD NEUROLOGY & DEVELOPMENT178 DHC - PAIN CLINIC 178 PEDIATRICS CRITICAL CARE 178 PEDIATRICS ENDOCRINOLOGY 178 CRITICAL CARE SERVICES 178 PALLIATIVE CARE 178 DHC - SPINE CENTER 178 TRANSPLANT PROGRAM 178 FAMILIAL CANCER 178 PEDIATRIC GASTRO 178 PEDIATRIC PULMONOLOGY 178 HOSPITALIST 178 PHYSICAL MEDICINE AND REHABILI 178 LITTLETON CARDIOLOGY 178 THORACIC SURGERY 178 CARDIAC SURGERY 178 PEDIATRICS - PLYMOUTH 178 MANCHESTER HEMATOLOGY 178 PEDIATRIC NEPHROLOGY 178 ORTHO:OUTPATIENT SURGERY 178 ORTHO:INPATIENT SURGERY TEAM 178

UNIT_COST 67 102 85 93 94 118 111 87 85 104 73 92 82 80 106 160 81 144 66 80 94 88 122 73 122 152 115 101 180 111 111 100 96 109 89 120 66 116 178 98 158 84 125 141 106 225 73 109 64 103 112

Cost to Charge Ratio 0.374837 0.5725 0.476865 0.522961 0.528213 0.664983 0.622051 0.489713 0.475191 0.586764 0.408809 0.515955 0.460348 0.450062 0.596601 0.900528 0.455348 0.808736 0.373163 0.448719 0.525545 0.49436 0.687174 0.407584 0.683848 0.855916 0.647854 0.569753 1.012197 0.622303 0.625449 0.564433 0.540545 0.614882 0.497337 0.672416 0.369404 0.65223 0.999264 0.550702 0.887567 0.470573 0.701888 0.794084 0.59664 1.262848 0.408191 0.613685 0.361612 0.578101 0.627433

Average Minimum Daily Cost Calculation • Average technical cost-to-charge ratio: 0.83 – Thus, average technical cost is $1,587 * (0.83) = $1,317

• Average professional cost-to-charge ratio: 0.60 – Thus, average professional cost is $178 * (0.60) = $107

• Average minimum daily cost is: technical cost plus professional cost = $1,587 + $107 = $1,694 • This average minimum daily cost of $1,694 is then multiplied by (11 patients times 20.9 days saved) to result in $389,450 saved • Of course, many patients are rounded on by more than one professional service, which can increase average minimum daily professional costs!

Appendix II: Any True Bottom-Line Savings? •

Correspondence on March 25, 2013 with Paul Gardent , MBA, Adjunct Professor of Business Administration, CoExecutive Director, The Healthcare Initiative, Tuck School of Business at Dartmouth; Senior Associate, Center for Leadership and Improvement, The Dartmouth Institute for Health Policy and Clinical Practice; MHCDS faculty :



“Figuring out hospital costs and cost-benefit is not easy. Here are a few thoughts on the issues that come up when trying to identify cost savings.



Many studies use the term “hospital costs” when measuring the impact of an intervention and they may go on to suggest that an intervention is lowering hospital costs. This then leads to an assumption that the hospital is seeing the reduction in costs and that their financial margins are improved. The logic then goes on to infer that of course the hospital would be interested in the intervention. The authors may even claim there is a business case for the intervention. Unfortunately from the hospital’s standpoint this is often not true.



As you have noted the first problem begins with the term “hospital costs.” Often what is measured are hospital charges to third party payers usually discounted by some percent as a proxy for payment rates. So in one sense it is “hospital costs” but it is hospital costs for the third party payers. From the perspective of the hospital what is being measured are hospital revenues or payments. The only way actual hospital costs are lowered is if expenses such as nursing costs, supply costs, food costs go down.



The second problem occurs when authors infer that because there is an overall positive cost benefit that there is a business case for the intervention from the hospital’s standpoint. This is not necessarily true. It depends on who pays for the intervention and who sees the financial benefit. It is amazing the number of times this gets overlooked. Leatherman et al wrote a great article on this issue titled “The Business Case For Quality: Case Studies And An Analysis” (Health Affairs, 2003). They conclude that “An investment that improves quality for patients may have different financial consequences for providers or payers.” They distinguish between the “business case” and the “economic case.” Often from a broad standpoint there is a positive cost benefit to an intervention (economic case) but there is not a business case for the hospital because the costs of the intervention are expected to be paid for by the hospital and the impact of the quality improvement (intervention) results in lower revenue to the hospital. From the hospital’s standpoint the intervention becomes a financial negative.



The third problem is the issue of fixed and variable costs. Often you can have a reduction of patient days but that doesn’t necessarily lead to a reduction in costs due to the fixed nature (at least in the short run) of many hospital costs. A good article describing this issue is The Savings Illusion – Why Clinical Quality Improvement Fails to Deliver Bottom-Line Results, New England Journal of Medicine, Dec 14, 2011. This issue is often ignored when making estimates of cost savings.”

Appendix II: Any True Bottom-Line Savings? •

Correspondence on March 26, 2013 with Bill Weeks, MD, MBA, Professor of Psychiatry and Community and Family Medicine at Dartmouth Medical School :



“I'm of the opinion that, if you've saved 200 patient days at DHMC, you've saved virtually nothing in terms of dollars. My reasoning can be captured in the attached article, but is based on the following (if any of them are wrong, then you might have some kind of cost savings) – 1. The same number of people were employed before and after the intervention (I.e., no one was fired, so there would be real cost savings). – 2. DHMC was not able to sell the capacity you unleashed (I.e., they didn't rent the beds to 'McDonalds' to generate revenue) - therefore their bond payment for the building was the same.



On the margin, you might have saved 200 or so meals, but, unless they were all on one day and therefore allowed the cafeteria to be order less food, thereby saving costs, you probably didn't really save much there either.



Generally, UNLESS THERE IS A QUEUE of profitable procedures/admissions waiting at the door, reduced LOS really just: – Gives personnel more breaks and less work. – Maybe saves some medication costs/Ringer's lactate, but probably not much (you really save the 'last' day of care, not the first, more expensive one - and further, the hospital can sometimes make money on the Ringer's lactated solution) – Generates more wasted food.



Sorry to be the bearer of this news, but it's a common misconception that reducing LOS 'saves' dollars. However, if the 200 bed days elimination were both consistent and predictable into the future, it might be that you could take credit for profits generated from re-using that freed up capacity, again, assuming that the replacement admission was profitable (which has more to do with insurance type than anything) and that administrators could 'count on' the 200 days savings in the future…..”

Appendix II: Any True Bottom-Line Savings? • Correspondence on March 25, 2013 with Anna Tosteson, ScD, Professor of Medicine, Professor of Community and Family Medicine, Professor of The Dartmouth Institute; James J. Carroll 1948 Professor of Oncology; Director, Comparative Effectiveness Research Program, The Dartmouth Institute for Health Policy and Clinical Practice; Director, Multidisciplinary Clinical Research Center in Musculoskeletal Diseases; Co-Director, Cancer Control Research Program, Norris Cotton Cancer Center; Associate Director, SYNERGY, Dartmouth's Center for Translational Science: •

“You are asking a good question that does not have a simple answer. Certainly the cost per day is not a constant in any way since it depends on level of care (setting) and length of hospitalization (early days typically are more costly when more tests etc are being run).



There should really be a good cost-accounting answer to the actual cost question, but I do not know who you’d need to engage at DH to get this specific information. Also, it is often information that is often not readily accessible. It is much easier to revert to some sort of charge, but you are correct that charges do not reflect actual costs of providing care. Often times there are cost-center specific cost-to-charge ratios available that could get you a step closer to actual costs.



In much of the cost-effectiveness work that I do, we are able to use regulated payment amounts as a surrogate for cost—simply because as long as that costing approach is carried through the valuation of alternative care pathways relative to one another remains valid.”

Appendix II: Any True Bottom-Line Savings? • Correspondence on March 25, 2013 with Sam Finlayson, MD, FACS, Adjunct Associate Professor The Dartmouth Institute and of Surgery; Kessler Director, Center for Surgery and Public Health, Brigham and Women's Hospital : • “The only experience I have converting charges to costs involves using cost-to-charge ratios, the numbers that payers like Medicare use to estimate how much a service cost the institution issuing the charge. These ratios are available from the billing folks at DHMC. There are ratios (usually around 0.65 or so) associated with lots of different cost centers. It is possible that if you get a list of cost-to-charge ratios for DHMC, you could find the right combination of cost centers to represent an inpatient day. ”

Appendix III: Real Significance of Quality Improvement Endeavors • Patients’ outcomes are improved (satisfaction, quality of life, prevention of hospital-acquired infections or adverse effects) • Resources are more appropriately utilized (a hospital bed is utilized by someone who needs a life-saving intervention, surgery, procedure, or treatment) – DHMC is experiencing more and more days of diversion, where we must turn away patients needing acute medical care!

• Staff’s and hospital’s morale is boosted—this is priceless!

Appendix IV: Excluded Cases/Outliers • 1) Patient was involved in an Office of Public of Guardian (OPG) of New Hampshire guardianship case in which extensive delays occurred due to guardian not being able to meet with assigned ward, which delayed discharge for at least a month following actual court-appointment of guardian. • 2) Patient required further intervention following start of guardianship process, including tracheostomy and PEG, and patient's guardian wanted her as close as possible to St. Johnsbury and thus waited for the first available bed to become available at Northern Vermont Hospital. • 3) Patient was first ever in hospital’s history to be denied Pre Admission Screening and Resident Review (PASRR) approval, which is a federal requirement that any time a patient needs care in a nursing facility they need to be screened for mental illness or developmental disability. This will ensure that if they require services in the facility that the facility they are going to can provide the appropriate services. – There is also a Long Term Care Medicaid eligibility process that has to happen. This is called MEA (Medical Eligibility Assessment). This is another state/federal requirement for placement in a facility where the state needs to approve the level of care a patient is requiring before they can be placed. This is for payment purposes.

Appendix V: Standardized NH SW Workflow • New Hampshire Guardianship Process • When a patient is admitted with a significant injury or illness with mental status concerns that result in a question of capacity, the Social Worker and team should assess the need for guardianship. (Refer to organizational process for guardianship determination – not yet available as of 11/2012) • RSA 464-A is the New Hampshire Statute for guardianship procedures. • RSA 547-B is the New Hampshire statute that describes public guardianship programs. • Link to NH site for guidance: • http://www.courts.state.nh.us/probate/guardianship.htm

Appendix V: Standardized NH SW Workflow • • • • •

DHMC Social Work Process Decision is made that patient lacks capacity to make medical decisions and guardianship is needed. Social worker identifies a guardian from one of the following options: –

Family member or friend – For those patients with family or friends willing to be guardian



Professional Guardian - When no family or friends are available or willing –See link for information to obtain a Professional Guardian.

• • • •

http://www.courts.state.nh.us/probate/proguardianshipinfo.htm –

• • •

Public Guardian - When there are no family or friends available or interested in being a guardian for the patient. “The Office of Public Guardian is a private non-profit corporation to provide guardianship and advocacy services to legally incapacitated adults in NH including those with developmental disabilities, mental illness, dementia and traumatic brain injury. The professional staff provides a wide array of services to clients on a fee for services basis and to qualified indigent clients through a contract with the State of New Hampshire.”

http://opgnh.com/ Social work assists with petition paperwork if appropriate (some families may have an attorney assisting them). Decision is made if the guardian needs to be over the person or the person and the estate (finances). Helpful checklists: • •

033 Guardianship of Incapacitated Person & Estate 034 Guardianship of Incapacitated Person

• • • •

Petition packet (be sure to read instruction pages) consists of:

• • • • • • •

d. Division of State Police Criminal Record Release Authorization Form (DSSP256) e. Department of Health & Human Services Record Release Authorization (NHJB-2171-FP) f. Letter from an MD about the patient’s lack of capacity and injuries. Be sure letter references “Serious and irreparable harm” if a guardian is not appointed. g. Cover letter from social worker requesting emergent guardianship of the patient, as well as reference of “Serious and irreparable harm” if a guardian is not appointed. (See letter Template) h. Petition fee of $180.00 (If patient/family cannot afford the fee, complete Application for Waiving Fee Care Management may consider payment of the petition fee when the Office of Public Guardian is involved. Contact Administrative supervisor Kelly Sheridan to request fee. She will need Patient’s name, Medical record number, amount, Probate court with address. Check should be sent to the social worker.)

a. Petition for Guardian of Incapacitated Person (NHJB-2165-P) b. Petition and Affidavit for Expedited Hearing (NHJB-2169-P) c. Request for Waiver of Personal Appearance (NHJB-2168-P)

• • • • • • • • • • • • • • • •

Social Worker keeps a copy of the complete packet. Completed original packet is mailed or dropped off by the family to the Probate Court for the town of residence of the patient. Notify Risk Management that a petition has been filed. Provide copy of petition to Senior Care Manager – Michele Blanchard - for scanning into Shared folder – Friends of Care Management. Notification of the hearing date will be sent to the social worker, along with the assignment of the court appointed attorney. The attorney will need to visit the patient prior to the hearing. Discuss with Risk Management if the hearing can be done by telephone and who will discuss this option with the court. Discussion with Risk Management about whether a representative from Psychiatry, Risk Management or Social work should attend the hearing. When the Social Worker receives notification that the guardianship has been granted a copy of the document should be scanned into the Medical Record and Risk Management notified so an alert can be placed in the registration system.

Appendix V: Standardized VT SW Workflow • VERMONT Guardianship Process • When a patient is admitted with a significant injury or illness with resulting mental status changes or baseline mental status concerns that result in a question of capacity the Social Worker or the team should question the decision making capacity and need for guardianship. (Refer to organizational process for guardianship determination – not yet available as of 6/2012) • Chapter III, subchapter 12, Title 14, Section #3060-3081 • Guardianship is an easier process in VT. Persons seeking guardianship can go to the probate court in person, and if the judge is available, may be granted a temporary guardianship that day. • Link to VT site for guidance: • http://ddas.vermont.gov/ddas-programs/programs-guardianship/programsguardianship-default-page • “Upon turning age 18 all Vermonters are presumed to be competent to make their own decisions and to have a right of self-determination. A parent is no longer considered the guardian of a child once the child turns 18. Any guardianship for an adult must be authorized by a court.”

Appendix V: Standardized VT SW Workflow • DHMC Social Work Process • •

Decision is made that patient lacks capacity to make medical decisions and guardianship is needed. Social worker IDs a guardian through meetings with family/friends. This will be for a: – – –



Social work assists with petition paperwork if appropriate (some families may have an attorney assisting them). Petition paperwork consists of: –



Private Guardianship for Mentally Disabled Adults (family or friend is identified as proposed guardian) or Public Guardianship for a Mentally Disabled Adult Age 60 or Older (there is no family or friends available or interested in being a guardian for the patient). When no family or friends are available or willing AND the patient is under age 60 – This is a challenge. The best approach is to consult with the Office of Public Guardian (pages 28 and 29 in the “Guardian Handbook” link at the bottom of the document). “Petition for Appointment of Guardian for an Adult Person” Probate Court Form No. 72

http://vermontjudiciary.org/eforms/Pc%20072.pdf –

“Statement of Proposed Ward’s Assets and Income” Probate Court Form No. 73



http://vermontjudiciary.org/eforms/Pc%20073.pdf



http://vermontjudiciary.org/eforms/Pc%20075.pdf

– – – –

“List of Interested Persons for a Guardianship” Probate Court Form No. 75 Letter from an MD about the patient’s lack of capacity and injuries. Be sure letter references “Serious and irreparable harm” if a guardian is not appointed. Cover letter from social worker requesting emergent guardianship of the patient, as well as reference of “Serious and irreparable harm” if a guardian is not appointed. (See letter Template) Appropriate fee of $105.00 • •



• • • • • •

If patient/family cannot afford the fee, complete waiver document Care Management may consider payment of the petition fee. Contact Administrative supervisor Kelly Sheridan to request fee. She will need Patient’s name, Medical record number, amount, Probate court with address. Check should be sent to the social worker.

Social Worker keeps a copy of the complete packet.

Completed packet is mailed to the Probate Court for the town of residence of the patient or it can be brought to the Probate court by the family. Faxed copies are not permitted. Notify Risk Management that a petition has been filed. Provide copy of petition to Senior Care Manager – Michele Blanchard - for scanning into Shared folder – Friends of Care Management. Discuss with Risk Management if the hearing can be done by telephone. Discussion with Risk Management about whether a representative from Psychiatry, Risk Management or Social work should attend the hearing. When the Social Worker receives notification that the guardianship has been granted a copy of the document should be scanned into the Medical Record and Risk Management notified so an alert can be placed in the registration system.

Appendix VI: Guardianship Process Monitoring Sheet • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Guardianship Details Patient name: DOB/Age: Town/State of residence: Insurance on admission: DPOA for HC?: DPOA for $?: Date of admission: Admitting service/Attending: Discharging service: Diagnosis: MSW name: Date identified guardian needed: Petitioner/Relationship: Proposed guardian/relationship to patient: Date Petition filed: Expedited hearing requested: Date of hearing: Probate Court: Name of Judge: Date Guardianship granted: Date final Guardianship paperwork received: Was Medicaid needed? Date Medicaid paperwork filed: Discharge date: Discharge destination:

Appendix VII: Justification of Inclusion of Cases • Of note, one guardianship patient (circa November 2011) had a LOS of 81 days which was not counted as an outlier. – Review identified at least two exceptionally long causes for delay which could not be justifiably classified as process outliers: • 1) From the patient’s initial psychiatric consultation for capacity to ultimate determination of incapacity took 27 days (as the patient initially did have capacity but subsequent and follow-up evaluations eventually indicated incapacity) • 2) From the time that the guardianship petition was submitted to the final determination of hearing date took 29 days – The initial guardianship petition was incomplete, turned back around several times, and hearing dates were rescheduled several times due to various logistic factors including staff availability & holiday schedule

Appendix VII: Justification of Inclusion of Cases • However, these two causes for delay could not be classified as distinct and separate processes from the guardianship process as delineated – They did not involve completely different guardianship processes, such as: • 1) our OPG case. • 2) unusual situation of requiring additional acute medical/surgical procedural interventions following initiation of the guardianship process. • 3) extremely unusual, hospital-first-ever denial of Pre Admission Screening and Resident Review (PASRR) approval, which is a federal requirement that any time a patient needs care in a nursing facility they need to be screened for mental illness or developmental disability. This will ensure that if they require services in the facility that the facility they are going to can provide the appropriate services.