Medicare’s proposed discharge planning changes at a glance
Learning objective
At the completion of this educational activity, the learner will be able to:
- Identify the proposed changes to the Conditions of Participation that affect discharge planning.
Discharge planning has long been a challenge for organizations, but proposed revisions to Medicare’s Conditions of Participation (CoPs) announced in November 2015 may make the process even more difficult. (See related article, Proposed rule focusing on discharge process could increase case management staffing needs in the January issue of CMM.)
In an April webinar called "Discharge Planning Realignment of Standards and Workflow," speaker Jackie Birmingham, RN, BSN, MS, CMAC, vice president emerita of clinical leadership for Curaspan Health Group in Newton, Massachusetts, said the proposal would represent "probably the biggest change that has been proposed in years for the CoPs." The changes could likely prompt a restructuring of case management functions to help ensure compliance with these new proposed functions.
Birmingham and fellow webinar speaker Janet L. Blondo, MSW, LCSW-C, LICSW, CMAC, ACM, CCM, C-ASWCM, ACSW, manager of case management at Washington Adventist Hospital in Takoma Park, Maryland, took some time at the end of the presentation to answer questions from the audience about the proposed rule and how it will affect case management and hospitals overall. Below are adapted versions of some of those questions and answers, which can help clarify some of the issues organizations may be struggling with related to these proposed changes.
Q: Does this proposal mean that we can send referrals to skilled nursing facilities (SNF) and home healthcare and they only present patients the choice of those accepting facilities?
A: Yes, that’s what it means. If you send referrals to postacute providers, we’ll use SNF as an example, and they look at it and they have the resources, the skills to meet that patient’s needs, and they have an empty bed when the patient is being discharged, you can show the options to the patient. If you have one option, then you have one to present to the patient. If you have 12 options, then you may want to use your clinical judgment and counseling and look more at the quality ratings to narrow the list down before presenting it to the patient. Medicare does not have a minimum list of providers to give to a patient. Some hospitals do. They’ll say you have to have three providers, but that’s only so that people are forced to have a backup plan should the first provider be unable to take the patient. So the answer is you can give the patient a list of only those that are available.
Q: We do physician-to-physician with transfers to acute care, but not to SNFs and rehab facilities. Is this now a requirement?
A: It’s not mentioned as a requirement in the discharge planning CoPs. But, in the view of continuity of care and safe transition of care, ensuring that the next provider can start the care. It is necessary to communicate to the next medical person who’s going to be taking care of the patient. It could be a doctor. It could be a non-physician practitioner. We believe that that would have an impact on readmissions if the person responsible for the care at the next level has a history of what happened to the patient in the current setting. So the medical information does need to be shared with whoever is going to be the medical provider in the postacute setting.
For patients being referred to an inpatient rehabilitation facility (IRF) from an acute care facility, it has to be physician-to-physician. The IRF physician must accept the referral. That was implemented maybe a year or more ago so that the benefit of the IRF for the individual patient would be clarified before they accepted the patient.
Q: Can you please clarify the requirements for critical access hospitals (CAH) briefly?
A: The CAH is a rural hospital and it’s one that is located geographically distant to a tertiary care hospital or a larger acute care hospital and they have been not required to do such rigorous discharge planning, but Medicare has said for those who are inpatients, they have to do planning for the patient. Now remember, they’re distinguishing between a discharge to home and a transfer to another hospital.
The CAH average length of stay is about 90 hours, 72?90 hours. I don’t know how many go home, but for those patients who go home directly from an inpatient stay at hospital CAH, the CAH has to do the same thing acute care hospitals do. It has to have a plan for all patients and it also needs to have a plan for follow-up for patients who are sent back into the community and not transferred to the hospital.
CAHs have been off the radar screen for a long time, but they are just what they say. They give access to critical services in rural areas. So some health systems have CAHs as their related partners so that those of you in an acute care hospital need to work closely with CAHs to help them understand the discharge planning and maybe if they’re in your system, do a combined system for follow-up care. Follow-up of the discharge patient to home, you see all the programs that are out there. There are some commercially available products. It’s a very time-consuming situation. If you call a patient who went home, you have to have a plan to address whatever concerns come up. So I applaud any CAH. CAHs usually have one person doing case management and that person does everything. I talked to one who was the supervisor of the operating room, the bed manager, the utilization reviewer, and the quality person because the CAH had 25 beds or less.
Q: Does the choice list given to the patient need to be kept in the permanent medical record?
A: That’s a great question and the answer is it depends on your hospital policy on choice. If your hospital policy on choice says that you must keep that file, then that should be in the medical record. It all goes back to what your hospital policy says. You may want to get it out and look at it. What does it say about documenting patient choice? Now, do you need to list everybody that you sent the referral to and only two accepted? That should be in your choice policy. The use and disclosure of HIPAA should be used as a basis for the answer to that question. I hope I’m not skirting the issue, but because Medicare will not tell you how to do it; it tells you, you must do it. It’s up to what your policy says.
Many people will document who the referrals were made to, but if you do use an electronic referral system that will be documented as you’re making the referral, when the surveyors come you may be asked to show in the electronic referral system where the referrals were made.
Q: At what point will these proposals be implemented by CMS?
A: I anticipate relatively soon. It likely won’t take as long as it did last time?1988 was when the amendment to the Social Security Act came out saying you will do discharge planning and then they kept evolving it. Because this is so big and such a big expansion, I imagine that it will take a little while but I don’t think it’s going to be too long. But the other piece of advice is that everybody should act as if this is the way it’s going to be. CMS published the blue boxes two or three years ago and there’s nothing in here that’s not logical, and if they don’t pass one thing, then I’ll say you should be doing it anyway because it has good outcomes. Remember in the blue boxes that came out from Survey and Certification May 2013 CMS said that it collected information from surveyors?from The Joint Commission, from the other [deemed] one and from state surveyors, and they said in hospitals where they had good scores. CMS took that information and put the advisory boxes and now they’ve taken the advisory boxes and converted them into standards. It’s so logical.
It’s so refreshing and when you have staff in the room, when you have new staff, when you’re asking an existing staff to do a new function, use these as your training tools because they tell you what the expectation is and then get your policies wrapped around it.
Q: What are the 10 sections of the discharge planning process?
A: The abstract of the CoPs lists those 10 parts of the discharge process, which include the following instructions:
1.Discharge planning must be provided by a registered nurse or social worker or other qualified individual
2.An initial assessment must be performed 24 hours after admission
3.The hospital must provide regular evaluation of the patient’s condition
4.A responsible practitioner must be involved in the planning process?that means, for example, a physician or nurse practitioner
5.The hospital must also consider caregiver- and community-based support
6.The patient and caregiver must be involved in the development of the plan
7.The plan must address the patient’s goals and treatment preferences
8.The facility must assist patients in selecting a postacute provider
9.The evaluation must be documented
10.The hospital must reassess its discharge planning process on a regular basis
To comply with No. 10, the organization would need to take all of your readmission data, your HCAHPS scores, and referrals that you’ve made to five-star, three-star, postacute providers and look at the readmission rate related to geography. Those types of things, and you have to document that in the minutes of your discharge planning meetings or in the utilization review committee meetings if that’s your reporting structure.
Organizations might also want to consider revising their assessments and including some of this information in assessments if the organization does a checklist, to have some of this information included so it can easily be shown that you’re addressing this topic.