Enhanced Care At Home (ECAH)

Tarlani has been recruited to be a part of Kaiser’s “Care At Home” pilot program. This program is meant to provide high intensive, collaborative care to patients who may be safer and more comfortable in the home than in a Skilled Nursing Facility (SNF).  The key is to front load visits to help the patient and caregivers to ramp up the rehab process to return to PLOF. Kaiser is looking to the therapist to determine what is best for the patient based on the presentation and how weak they are and what they are willing to do.

During the first 14 calendar days after SOC, PT is authorized for 6-7 visits while OT is authorized for 3. After this 14 day period, PT/OT may continue with more intensity of visits or taper off based on justification of patient response to treatment.

Please:

- Encourage the patient and family to get up and move, participate in functional exercises, and not to stay in bed. Staying in bed causes more weakness.

- Be specific and detailed in documentation and patients response to treatment

Recommended PT F/D: Can be altered if F/D is starting at the end of the week.

• 3w2 OR 3w2 1w1 OR 1w1 3w2

Recommended OT F/D: 1w1 2w1 or 2w1 1w1 (Focus on ADL re-training and performance not just upper extremity exercises but more functional ADL)

Recommended ST F/D: 1w1 2w2 or 2w2 1w1 

• 3-5 visits per week is ideal, gaps in care should be avoided. Weekend visits cannot be unilaterally skipped but may be skipped if the patient is being seen Thursday+Friday or Friday+Monday

• For patients that are more weak and debilitated, it is okay for PT/PTA to see the patient more frequently (4-5x/week) for the first two weeks.

• When high frequency is complete, do not transition the patient to 1x/wk F/D, it should be at least 2x/wk.

REPORTING: Please call Margarita at 818.241.4444 to provide a quick report after your Evaluation and DC

If patient is refusing to be seen on specified date, please report to Gennalynn 818-241-4444 ext 121 so she may discuss with patient. Patients are aware that they need to be seen and are at risk of losing their ECAH program if visits are missed.

For this visit-type, Tarlani requires all clinicians assess and document all transfers and ADLs on the Evaluation documentation. Kaiser requires a functional assessment form be completed for all assessment visits. This can be found under the blue "other forms" button

If patient has a caregiver, please document the name and the relationship to the patient in their notes. If the patient does not have a caregiver, please notify us as soon as possible. Please also list the DME (if the patient is using any) in the notes. The more information we have the better.  

If the patient is undergoing dialysis or any other type of care, the therapist is allowed to inform or advise the patient/pcg they can visit the patient prior to their appointment. Dialysis is normally in the afternoon around 2:00pm. Patients under this program are aware and agreed to be seen on dialysis days when they signed up for this program. 

As much as possible, please try to avoid missed visits. If a patient refuses, please report to us as soon as possible  so we can notify Kaiser.

Patient should be seen on the day (date) accepted the patient for eval. Therapists do not need to call right away but they need to call the patient at least the night before the visit. Missed visits are NOT OK for evaluations. Evaluations need to be done as is. The therapist needs to call patient's the day before to secure an appointment. Please do not call patients the same day. They will most likely not be available.