10 things you should know to ensure successful discharge planning

Learning objective

At the completion of this educational activity, the learner will be able to:

• Identify strategies to comply with proposed Medicare changes to the discharge process

One of the more challenging aspects of a case manager’s job is helping to ensure a patient successfully transfers from the hospital to the next level of care. Under a set of proposed revisions to Medicare’s Conditions of Participation (CoP) announced in November 2015. This job may get even harder, more specific, and apply to more patients. The changes, among other things, will require hospitals, including critical access hospitals, to create discharge plans for more patients. Case managers will need a more direct plan to include patients and their caregivers in the discharge planning process, in particular taking into account their individual "goals and preferences." This discharge planning process will also need to start sooner?within 24 hours of admission instead.

So what can you do to ensure your organization is up for the challenge? In an April webinar titled "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, and Janet L. Blondo, MSW, LCSW-C, LICSW, CMAC, ACM, CCM, the manager of case management at Washington Adventist Hospital in Takoma Park, Maryland, offered up some compliance tips that you can use to ensure your hospital is ready:

1.Assess your current discharge process. Under the proposed changes, the discharge planning process needs to start in the first 24 hours after the patient arrives at the facility. You’ll need to identify how your current processes work in order to make sure they comply with this timeline. Identify your current workflow?specifically, who does what, why they do it, and how it’s done. Ask the following questions:

• What is your current case management model?
• Who’s on your team?
• What’s their role?
• Who does the screening right now in the current
• Who does the patient assessment?
• Who makes referrals when you need to refer patients for services?
• In your current model, do the nurses perform the assessment for patients who go home while the social workers do the placements? Or do you have nurses and social workers assess everyone? "If you’re having all your patients assessed right now, well, you’re ahead of the game already, because that’s the new proposal," said Blondo.

Also think about why your processes were designed the way they are. "If you have it on one unit a certain way and not on another, think about what you need to do to change your practice so that perhaps every unit you can do assessment on every patient," said Blondo. "If your model is something that doesn’t seem to make sense with the proposal, what can you do to change it?"

Changes to bring the model in line could include adding technology (e.g., laptops, tablets) to speed up the process, adding staff members, or reassigning current staff members. "Perhaps some of your social workers can do UR," said Blondo. Alternatively, maybe a staff nurse can do an initial assessment instead of a case manager, or perhaps a nonclinical staff member can take over certain tasks. Taking the time to examine your current processes and think about how they can be switched up to meet the new requirements will give you the foundation for a new plan.

2.Drill documentation. Hold physicians accountable for following through and documenting discharge plans and dates. "If they’re documenting in the chart the discharge date and plan, that makes your job a little easier, because you have that in the chart already and can discuss that with the patient and their family," said Blondo. Take advantage of pre-procedure assessments by ensuring they are included in the chart, then making sure staff members follow through on that plan. "You don’t want Joint Commission or the state coming to do their survey and then you find out the assessment is not getting done because your staff has decided they want to do something different. So make sure everyone is doing the same," said Blondo.

3.Focus on delays. Use these potential discharge changes in the CoPs as an opportunity for process improvement. Look at what’s causing delays in your current process?use this information to improve systems and boost patient satisfaction. "You’re going to improve, perhaps, length of stay with this increased attention with discharge planning," said Blondo.

4.Make rounds count. If you are currently using rounds, examine what they’re being used for and how they’re working. Blondo says it’s important to ask:

• Are rounds being used for discharge planning?
• Are they used for the patient experience to improve your scores?
• Are they used for throughput or for some other reason?

After thinking about the current purpose your rounds serve, consider how they can be modified to fit your new objectives. "Many people just do one type of rounds per day, but you could actually be creative with these. There are some hospitals that I know of that divide rounds into different parts of the day," said Blondo. "For instance, you might want to think about doing rounds early in the morning for those patients that will be discharged [later] that day." The discussion could center on determining whether those patients are prepared to leave and have the right resources. Another idea is to add rounds to the short-stay area or outpatient area for procedures done late in the day. "And if you have case managers in the emergency room, you could ask them to round for those areas, catching any patients that might need something late in the day after your regular case management staff have left," said Blondo.

5.Understand patient options. This topic includes both big-picture and smaller issues. Case managers should focus on patient-based issues, which relate to talking to the patient, as well as on setting the patient’s broader goals and preferences. The organization’s systems must be set up to give patients a choice of postacute options. But keep in mind, when working with patients, you’ll always come across those who don’t like what you’re doing or who don’t agree with you and want to go another direction. "You need to have something standardized and something that you can fall back on when you’re presented with a patient and family who, in their eyes, have a reasonable goal and clinically or medically or psychosocially, they don’t," said Birmingham. Staff members must understand the concept of patient choice. "The staff must be comfortable that they are doing the right thing for the patient and the right thing for networks and the right thing for the organization."

It’s also important for staff to understand that the patient has the right to refuse the plan. "[The patient] may be in denial. They may be suffering grief," said Birmingham. The hospital should have a policy for patients leaving against medical advice (AMA), but case management must have its own discharge planning policy for those leaving AMA. In these instances, it’s not just enough to have the patient sign a paper, but rather actively assist the patient with the transition by ensuring that he or she has transportation and needed prescriptions. Even though there is an exemption for patients who signed out AMA and are readmitted the hospital, the hospital should have a plan for how to work with these patients, said Birmingham., said Birmingham.

You should also consider planning for a patient’s deficits related to loss of functioning, whether it be ADLs or IADLs. Birmingham recommended asking the following questions:

• Is the patient medicated and therefore unable to participate in planning?
• Does the patient need to have a conservatorship?
• Is there conflict among the patient’s children or the patient’s siblings?
• Does the patient have a family or responsible person?
• Is the patient appealing the discharge?

A plan should be in place to address the answers to these questions.

6.Help patients achieve their goals. This is something that organizations should have been doing all along, but there is much more emphasis on it now. A problem arises when the patient’s goals and preferences don’t align with what is medically necessary or what is reasonable and necessary. In these instances, it may be wise to involve social workers. "Look at some of the things that patients might be going through?denial, grief that might affect their decision-making at the time," said Birmingham. "With the family dynamics, there might be family members trying to convince the patient to make a decision that isn’t really what the patient wants." Ultimately, the goal is to help the patient make the decision that is best for him or her, but also to think about what is medically the best option.

7.Involve the physician. Physicians are an integral part of discharge planning, so it’s important to make sure they are actively involved in the process. This communication between the patient and the physician needs to be sensitive to generational and cultural differences. "To involve perhaps some of the older patients, just have the doctor come in and say, ‘We want you to do this,’ " said Blondo. "That might not work for younger generation or baby boomers who are used to rebelling, but if you have the doctor come in and say, ‘This is what we’re recommending and this is why’ and help the patient to understand why it is recommended."

While it may be easier to foster good communication if you’re working with a hospitalist, it can be more of a challenge if the physician is community based. "How will you manage when the patient is transferred to another facility? It’s not been a problem if you’re transferring the patient to another hospital, but if that patient is being transferred to a SNF, there haven’t been that many times when the doctors have called to the doctor in that SNF to give them an update," said Blondo. Have a plan in place to ensure the communication lines are always open.

8.Work to decrease unplanned readmissions and improve patient outcomes. "Readmissions are an old problem with new incentives," said Birmingham. Readmissions can be strongly linked to location and patient access to resources, which shows that they often depend on factors other than the medical treatment the patient received. This underscores the importance of ensuring your patients have access to things like food and transportation when they leave the facility. "Is your [patient’s] area in a food desert? No car, no supermarket store within a mile?and that makes a huge difference," said Birmingham. If this is the case, your organization might want to develop or contact an existing program that delivers food to the homes of qualifying individuals. "Home health agencies could do that too for some programs to be able to provide some fresh groceries to some patients," she said.

Also find out if your patient has been readmitted in the past, a risk factor for readmissions. "You can look to see if a patient is readmitted from an acute level of care, but you’ll need to ask the patient if they’ve been in the emergency room in the past 30 days, if they were admitted from a facility SNF," said Blondo. "Often, that information is sent with them to the hospital, but you can ask them." Ask if the patient was receiving home health services prior to admission. Encourage physicians to include this type of information in the history and physical to ensure it won’t be missed.

"We’re never going to be perfect and have no readmissions, because some patients have a legitimate need to come back to the hospital within those 30 days, but look at your readmissions. Learn from who is coming back and think about what strategies you can put in place for that," said Blondo.

9.Keep the focus where it belongs. "Discharge planning is a patient-centered function," said Birmingham. "You can do utilization review without talking to the patient. You can do quality improvement without talking to the patient and family, but you can’t do discharge planning." For this reason, discharge planning can be very rewarding to clinicians who want to be involved in the patient’s care, and to be there for them when they’re at their most vulnerable.

10.Take your cues from the experts. While Medicare’s CoPs aren’t a cookbook on how to run your organization, they are a good place to start because they’re based on years of evidence. "Many of the changes in the original CoPs happen because commenters send in a comment to CMS and CMS responded and actually changed the proposed rule," said Birmingham. "Now, will they change these proposed [discharge planning] rules? I don’t think so, and I think that’s because they’ve been published as interpretive guidelines for over two years." That means these discharge changes are likely here to stay. Like all other CoPs, they should be blended into your workflow and your strategies and partnerships with other departments, said Birmingham.

HCPro.com – Case Management Monthly