Discharge Planning Advisor: DP staff feel the burden of prospective payment

Forms take more time, patients harder to place

Nursing facilities look at potential patients differently since the advent of Medicare’s prospective payment system (PPS), a turn of events that those in the industry say has made discharge planning a more complex and time-consuming process.

More detailed and demanding screening assessments by nursing homes probably have increased the time discharge planners spend completing referral forms by 25% to 50%, says Kathy Reilly, RN, MS, A-CCC, CPUM, manager of resource management at MidState Medical Center in Meriden, CT.

Patients with a high cost of care — like those on total parenteral nutrition or expensive medications or who need high-tech durable medical equipment — are becoming more and more difficult to place, she adds.

Because nursing facilities are reimbursed according to the acuity of the patient rather than on a per diem rate, much effort must be spent documenting the factors that give evidence of that acuity, Reilly notes. If, for example, a patient has received intravenous (IV) medication within three to five days of admission to a nursing home, that treatment is reflected on the "minimum data set" (MDS), the patient acuity measurement tool that provides the medical information on which resource utilization groups (RUGs) categories are based. The RUGs category determines the amount of reimbursement.

Under the PPS system, Reilly notes, the number of minutes of therapy received per day gives the patient a different RUGs "score." The exact date a patient is taken off a ventilator after surgery must be noted because that, too, may put the case in a higher reimbursement category, she adds.

But while more acuity translates to more reimbursement, there is a point at which the payment tops out, so that nursing facilities can find themselves absorbing the extra cost of caring for the most acute patients, she says.

"These are the patients we see staying a little bit longer in hospitals, because they need to be more stable, and to receive less high-tech treatment modalities" before they can be placed in post-acute care, she points out.

"We have to know the facilities in our area that can and still do accommodate some of these higher-acuity patients. Some facilities have made the decision not to provide services for patients on ventilators or IV medication," Reilly says.

Nursing homes, meanwhile, are calling on hospitals not only to give them the detailed information they need, but provide it in a more organized fashion, Reilly adds. Formerly the admissions director for a facility with 30 short-term rehabilitation beds and another 300 skilled nursing beds, she has seen the issue from both sides.

Although most hospitals have changed their referral forms to reflect the screening assessment the nursing homes use, a more standardized system is needed, she says. "Having had experience at the nursing home dealing with multiple referral sources, I can tell you that if you look at the referral process at 30 different hospitals, there are probably 15 to 20 ways of doing it," Reilly says. "Some type of standardization might alleviate some of the problems."

It also would help remedy the situation if all nursing facilities would accept a "common nursing home application" from the hospital, she notes. Although most accept the common form, Reilly adds, there still are some cases in which the family has to go to the facility in person to arrange a placement. "It’s more time-consuming and complicated, and it’s a burden on patients’ families."

The National Association of Subacute and Postacute Care (NASPAC) has developed a prescreening assessment tool for skilled nursing facilities (SNFs) that follows the language of the MDS and the PPS, notes Diane Brown, a member of the board of the Vienna, VA-based organization and president of JSC Inc., a Boston firm that specializes in education, consulting, and training for post-acute care. Although the form was designed for use by the SNF’s nurse assessment coordinator, it would be "a marvelous tool for the discharge planner to use on the hospital side," Brown says.

Another restriction on the discharge process is that managed care companies often have contracts with organizations that accept risk for some of the home health and nursing home placements, Reilly points out. That means another entity gets to weigh in on where the patient will receive care, she says. "That adds another layer to the complexity of discharge planning."

"[Discharge planning] is a very complex role," she says. "You can’t just say, Here’s the manual, go to it — identify the patients who need the complex planning.’ There’s not just a clinical perspective. You have to look at the psychosocial, the financial [factors]. They all affect the process rather dramatically."

The complexities of PPS can affect the patient’s length of stay, Reilly notes. "That’s a negative financial impact, and it can be a negative clinical impact," she says. "We know that patients who stay in the hospital for a long time are at risk for certain infections, and hospitals are not in the business of being rehab facilities."

Working collaboratively with post-acute providers can help discharge planners identify early on some of the barriers to placement, she says. "You can also work with the physicians, suggesting that if it’s clinically appropriate, we need to change this treatment modality because we can’t provide it in this community."

An assessment of the PPS, conducted by the Office of the Inspector General’s (OIG) Office of Evaluation and Inspection not long after the system’s 1999 inception, found that nursing homes were changing their admissions practices in response to the new system.

About half of all discharge planners surveyed for the OIG report said that nursing homes were requesting more detailed information about the patient and were more consistently coming to the hospital to directly assess the patient before making admissions decisions.

When asked which types of patients had become more difficult to place, the majority of discharge planners identified patients who required extensive services, specifically mentioning those who need intravenous feeding, intravenous medication, tracheostomy care, or ventilator/respirator care.

That report, Early Effects of PPS on Access to Skilled Nursing Facilities (available at www.dhhs. gov), concluded that there was no direct evidence that Medicare patients were not receiving the SNF care they required.

The reason the complexity of the PPS system is coming to the forefront now as a problem for discharge planners, suggests veteran discharge planning and case management consultant Jackie Birmingham, RN, MS, CMAC, is that it’s part of an overall problem with bed management.

"I think some nursing facilities started doing more scrutiny and calling the nursing units for more and more information, and I think this resulted in delays in discharge planning causing a backup of patients," says Birmingham, who is vice president of professional services for Curaspan Inc., a Newton, MA-based company that produces eDischarge, an on-line discharge system.

"It’s probably one small part of the overall problem of bed capacity days," she adds. "Everyone is looking at ways to streamline the process now that there are internal (length of stay, bed capacity) and external (patient admission status and reimbursement case mix) pressures."

Electronic completion of forms can provide some relief for overburdened discharge planners, Birmingham says. "Filling out forms takes so much time. First you have to find the right form, then start it, and if anything changes for the patient, you have to start over. Electronic forms are easier to read, and there is speedier transmission."

Reilly’s department has a patient transition coordinator who works with discharge planners, helping to facilitate the movement of communications with nursing homes, she says.

Electronic forms would further smooth the process, Reilly agrees, "putting the professional doing the professional role."

[Editor’s note: Kathy Reilly can be reached at (203) 694-8503 or by e-mail at kreilly@harthosp.org. Jackie Birmingham can be reached at (617) 663-4831 or (860) 668-7575, and by e-mail at jbirmingham@curaspan.com.]