Compliance Mentor - December 2015

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Discharge Planning: Proposed Changes Six Standards

It was only a year ago that CMS published the final discharge planning worksheet and a little more than two years ago when the hospital discharge planning standards were totally rewritten. They were 39-pages long and the number of standards decreased from 24 to 13.

Now CMS is proposing 20 pages of changes to the discharge planning standards and process. Once they’re final, CMS will add interpretive guidelines and publish them on this page and in the Federal Register.

There is a 60-day comment period. CMS will review the comments and then issue the final regulations.

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Webinar on the changes

AHC Media is conducting a webinar covering the proposed changes on Feb. 8 from 3 to 4:30 PM Eastern. For cost information and to register contact customer services at (800) 688-2421.

These regulations are aimed at helping to prevent unnecessary readmissions. Reducing hospital readmission helps minimize patient complications, improves the safety and quality of care, helps lower healthcare costs, and leads to reduced penalties from unnecessary readmissions. There are 2,680 hospitals that have forfeited $420 million because of their higher readmission rates. CMS notes there are too many instances where patients did not know their diagnosis, their current medications or their side effects.

CMS says hospitals, including critical access hospitals, need to improve their focus on behavioral health patients and those with substance-abuse disorders. Hospitals should consider options that include telemedicine services. A federal law on telemedicine was passed in 2011.

CMS also says some hospitals do not have a thorough understanding of community services that impact the discharge planning process. The lack of collaboration and teamwork has resulted in unnecessary readmissions. Hospitals should consult with the Aging and Disability Resource Centers, the Centers for Independent Living, or the Substance Abuse Mental Health Services Administration’s treatment locator.

The proposed changes focus on the patient’s goals and preferences and they must be incorporated into the discharge planning process. Instead of the hospital preparing the discharge plan and presenting it to the patient, patients become active partners in planning their post-charge care.

The hospital’s discharge planning policy must be developed with input from the medical and nursing staff along with other relevant department such as social workers and discharge planners. It must be in writing and approved by the board.

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Who do the changes apply to?

The discharge planning process applies to inpatients, specific emergency department patients, and same-day surgery and outpatient observation patients. A qualified person must coordinate the discharge needs evaluation and discharge plan. Identification of anticipated discharge needs must begin within 24 hours of admission. The discharge planning process must be done before the patient is discharged home or transferred to another facility such as a long term care facility.

Some hospitals perform a discharge planning evaluation for every patient. For some patients it may be as simple as explaining discharge instructions and having the patient repeat them. The social worker or discharge planner reviews the chart daily to determine if there is any change in the patient’s condition. Hospitals that do this will prevent jumping through many of the hoops in the discharge process. The proposed regulations state that the discharge process regularly reevaluates the patient’s condition to identify any changes that would require modification of the discharge plan.

The physician or practitioner responsible for the patient’s care must be involved in the process or establish the patient’s goals and preferences. Many times it is an interdisciplinary committee that is involved.

Here’s an example. A patient has suffered a severe stroke. The patient wants to go to a rehab center near home. The patient wants to be ambulatory without using a walker or cane. The interdisciplinary committee is composed of the attending physician, the pharmacist, nurse, social worker, dietician, physical therapist, and occupational therapist. Also included was the patient’s support person or patient advocate.

In the discharge planning process, the hospital must consider the patient, caregiver, or support person’s ability to perform necessary care. The patient has a wound dehiscence after surgery and must pack the wound and apply a dressing. The patient is also going to be discharged with a Jackson Pratt drainage tube and a Foley catheter. The patient decides to go home with the assistance of a home health nurse and the support person.

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Redrafting the evaluation form

The hospital may want to consider redrafting the discharge planning evaluation form to include the CMS requirements. This includes, but is not limited to, admitting diagnosis, relevant co-morbidities, past medical history, past surgical history, anticipated needs, readmission risk, and relevant psychosocial history. Communication needs must be assessed, including language barriers, diminished eyesight, diminished hearing, and self-reported literacy of either the patient or caregiver. The assessment must include the patient’s goals and treatment preferences and access to non-health care services. This might include someone to transport the patient to their first appointment, preparation of meals when needed, shopping, or housekeeping services.

The hospital must assist patients or their families select a post-acute provider. This includes home health services, a skilled nursing facility, an inpatient rehab facility, or long-term care acute hospitals. The hospital must share data on the five quality measures and on resource use measures. Hospitals must take into account quality, resource use, and other measures in discharge planning.

Often an RN will do an admission assessment. The results may prompt notification of the discharge planner or social workers. The patient’s discharge needs and discharge plan must be documented in the medical record.

The hospital must assess its discharge planning process regularly. It must review a sample of discharge plans and include reviews of patients readmitted within 30 days.

If a patient is discharged home, CMS has mandates for the discharge instructions. These must be provided to the patient and/or their support person. If the patient is going to be seen by a post-acute care provider, such as a home health nurse, then these must be provided to them as well. The discharge instructions must include written information on warning signs and symptoms that would indicate the patient needs to call their doctor or return to the hospital.

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Prescriptions and medications

The discharge instructions must include any prescriptions and over-the counter medications, including the name of the drug, indication, and dosage. Any significant risks and side effects must be disclosed. The discharge instructions must include reconciliation of all discharge medication with the pre-hospital medications.

The written discharge instructions must include follow-up care, pending tests, planned additional testing, and contact information. The contact information, including phone numbers, must be included for any physician, provider or supplier who is going to provide follow-up care or provide supplies or equipment.

It is important to note that a copy of the discharge instructions and discharge summary must be sent to the practitioner or physician who is responsible for the follow-up care within 48 hours. Physicians or LIPs who discharge the patient may need to immediate dictate the discharge summary. Health Information Management will need to get it transcribed and ensure it gets into the hands of the follow up practitioner within this 48 hour time frame. Pending test results must be sent to the provider within 24 hour of their availability. This will definitely create a challenge for some patients.

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Continuity of care

Hospitals may also want to consider redrafting their continuity of care or transfer form. Now the proposed regulations list a number of things that need to be included in the transfer form. This includes demographic information including name, sex, date of birth, race, ethnicity, and preferred language. The transfer form must include advance directives, course of illness and treatment, procedures performed, diagnosis, lab tests, results of diagnostic testing, consult results, functional status assessment, psychosocial assessment, including cognitive status, social support, behavioral health issues, medication reconciliation, allergies, immunizations, smoking status, vital signs, implantable device identifier, and patient goals and preferences.

Generally, in the past if a patient needed long term care or home health, the patient was informed about their freedom of choice. They were given a list of ones that served the geographical area to pick from. This continues but also applies to inpatient rehab facilities and long term care hospitals. If the patient is in a managed care organization, it must disclose which ones are accepted and must verify them. The hospital must document that the list was given. The patient is not required to have the patient sign this but some hospital do have the patient sign an attestation to this effect. The hospital must continue to disclose any financial interest in any of the skilled nursing facilities or home health agencies.

There is also required discharge planning regulations for home health agencies. Home health agencies should review these carefully. There are similar discharge planning requirements for critical access hospitals.

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The IMPACT Act

The IMPACT Act (Improving Medicare Post-Acute Care Transformation) became law in 2014 to clarify their discharge options.

Imagine an orthopedic unit with four patients who had total knee replacements. Patients are given four options of post-acute care (PAC) providers: home health services, an inpatient rehab unit, a long-term care hospital or a skilled nursing facility. How do patients make decisions when there is no clear data to assist them in this process?

Also, how does one determine payment reform with bundled payments, neutral site payments and value based purchasing in a system where this data is clearly lacking? One way is standardize the assessment data so we can compare apples to apples.

All four PACs must measure:

1) functional status and changes in function;

2) skin integrity and changes in skin integrity;

3) medication reconciliation;

4) incidence of major falls; and

5) patient preference regarding treatment and discharge options.

These new quality measures will be done through the post-acute care assessment instruments. This must be done by Oct. 1, 2018, for SNF, IRF and LTCH and Jan. 1, 2019, for HHA.

All four post-acute care providers must complete same standardized assessment. The assessment tool must be interoperable to allow for exchange of data among the providers. Using common standards and definitions will help providers coordinate care and improve Medicare patient outcomes. The standardized patient assessment data shall include functional status, cognitive function and mental status, special services and interventions (chemotherapy, ventilator, central line insertion, TPN and dialysis), medical condition, impairments (sensory loss, incontinence, visual loss, inability to swallow), prior functioning levels, and any other categories as stated by the secretary to be necessary and appropriate. Hospitals and other PACs will have to revise their assessment tool to capture this patient assessment data.

There are requirements for resource use measures. The secretary needs to specify resource use and other measurement date by Oct. 1, 2016. This must include at a minimum: 1) Medicare spending per beneficiary; 2) discharge to community; and 3) hospitalization rates of potentially preventable readmissions.

This allows for comparison of the data across all four providers.

This new law will mean more work for post-acute care providers. Failure to follow these would result in payment reductions. These changes could result in a different billing structure in the future which could include site neutral payments or bundling. Providers should review this law carefully. Providers need to create a process to capture these quality measures and put into place quality improvement activities.

A copy of this federal law is available at no charge here.

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