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Monday, April 28, 2014
  Clinical Accuracy Spoken Here  

CV Risk: Stroke Transitional Care

Medicare A Criteria for admission to Skilled Nursing Level of Care:

  • 3 day hospital stay
  • Daily skilled care ordered by a Physician
  • Clinically complex nursing needs, e.g. wound care, IV therapy
  • Rehabilitation needs
  • Medicare certified facility

Medicare A Criteria for admission to Acute Rehab Hospital Level of Care:

  • Able to engage in three hours of therapy per day
  • Must demonstrate functional improvement on a weekly basis

[Reference: CV Risk: Stroke and MI, Module B, Stroke CM Role]

  Excellence in Case Mgmt  

CV Risk: Determine Rehab Goals

The role of the CM in MI and Stroke care involves disease management strategies, application of cost control strategies and quality-of-care techniques.

Transdisciplinary evaluations will need to be conducted to determine the appropriate short and long term rehabilitation goals for the patient.

The Case Manager will be an integral player in the coordination of the overall plan and help determine what is needed to discharge a patient to the next level of care?

[Reference: CV Risk: Stroke and MI, Module B, Stroke CM Role]

  Improving Patient Care...  

CV Risk: MI Transitional Care

Medicare criteria for cardiac rehabilitation programs include:

  • Have a documented diagnosis of AMI within the preceding 12 months; or
  • Have had coronary bypass surgery; or
  • Have stable angina pectoris; or
  • Have had heart valve repair/replacement; or
  • Have had PTCA or coronary stenting; or
  • Have a heart or heart/lung transplant.

[Reference: CV Risk: Stroke and MI, Module C, MI CM Role]


Tom RasmussenTom Rasmussen
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