Discharge planning takes spotlight as VBP focuses on efficiency
Executive Summary
Hospital efficiency of care, a new domain in the Centers for Medicare & Medicaid Services Value-based Purchasing Program, bases hospital scores on spending three days before admission through 30 days after discharge.
• Case managers need to take the time to develop a discharge plan that works and look at cost-effectiveness as well as appropriateness of the level of care, experts say.
• Because the data used for this measure is risk-adjusted, it’s crucial for the documentation in the medical record to clearly and accurately reflect the patient’s severity of illness.
• Become familiar with all the potential discharge destinations and spend time with each provider, experts recommend.
Next level of care is increasingly important
Beginning with admissions on or after Oct. 1, 2014, your hospital’s reimbursement under the Centers for Medicare & Medicaid Services (CMS) Value-based Purchasing Program is going to be affected by how much a patient’s care cost for the time period beginning three days before admission and continuing through 30 days after discharge.
"The expectation is for hospitals to pay attention to what happens to patients before admission, such as observation services as an outpatient, and the services they receive for 30 days after discharge. Hospitals need to ensure that patients are discharged to the setting that can provide the most effective care and that the transition goes smoothly," says Danielle Lloyd, MPH, vice president, policy development and analysis for Premier healthcare alliance.
Medicare spending per beneficiary, also called hospital efficiency of care, makes up 20% of a hospital’s value-based purchasing score in fiscal 2015 and will rise to 25% in fiscal 2016.
Hospitals’ scores on the hospital efficiency of care measure that affect the fiscal 2015 payment period have already been tallied and are posted on CMS’s Hospital Compare website. The website shows the ratio for each individual hospital compared with the state average and national average.
Medicare spending per beneficiary includes all Medicare Part A and Part B expenditures except for Part B drugs beginning three days before admission and continuing through 30 days after discharge. Hospital scores are based not just on Medicare costs while patients are in the acute care hospital but for expenditures during the whole window of time. Any payment Medicare makes on behalf of a beneficiary is included. If patients are transferred to another hospital, if they go to a skilled nursing facility or are discharged home with home health, it’s all added into the total.
In value-based purchasing, the measurement period is well in advance of the payment period. "Hospitals didn’t have much opportunity to impact what they will be paid for hospital efficiency of care in fiscal 2015. They have to work on improving their performance in the future," says Susan Wallace, MEd, RHIA, CCS, CDIP, CCDS, director of inpatient compliance for Administrative Consultant Services, a Shawnee, OK-based healthcare consulting firm.
Risk adjustment
Case managers should recognize that CMS is risk-adjusting the data used to calculate Medicare spending per beneficiary based on what is coded on the bill, Wallace adds.
Factors for risk adjustment include age, gender, past medical history, and other diseases or conditions that could increase their risk.
"Since the data is risk-adjusted, it’s important for the documentation to clearly indicate the severity of illness. Case managers should make sure that physicians include detailed information on all of the patients’ diagnoses to accurately reflect severity of illness," she says.
Case managers can have a major influence on their hospital’s efficiency scores because the discharge plans they create and the effectiveness of transitions to the next level of care affect what it costs Medicare to provide services after discharge, says Jackie Birmingham, RN, BSN, MS, CMAC, vice president emerita of clinical leadership for Curaspan Health Group.
Hospitals have the opportunity to ensure that patients go to the right place the first time, she says.
"Case managers need to start thinking like finance managers," Birmingham says. "It’s not necessarily the right thing or most efficient thing to discharge patients to the least expensive level of care. Patients need to be discharged to the appropriate level of care that can provide everything they need to continue their recovery," Birmingham says.
Case managers should start looking at what is best for the patient in the long run, and sometimes that’s not just getting them out as quickly as possible, she says.
"Earlier discharge is good, but in today’s reimbursement environment, case managers also need to look at other things. If the discharge plan fails and a patient is readmitted, the cost of care can soar since often the readmission costs more than the original hospital stay," she says.
CMS has expressed concern that hospitals often discharge patients with complex needs to skilled nursing facilities because it is easier than lining up all the equipment and therapy the patients would need if they were discharged to home, she says.
That’s why case managers need to consider all options, including keeping patients in the hospital a little longer to cut down on post-discharge expenses, she adds.
The emphasis on creating a successful discharge plan increases the need for collaboration between case managers and the rest of the hospital team, particularly if the case management role and the discharge planning role are separate, says Deborah K. Hale, CCS, CCDS, president of Administrative Consultant Services, a Shawnee, OK-based healthcare consulting firm.
"If you have a case manager facilitating care in the hospital and a discharge planner who develops a discharge plan, communication between the two is vital in order for the discharge plan to take into account the social issues and the clinical issues," Hale says.
As CMS puts more emphasis on the cost per beneficiary, case managers need to consider all the options available for the patient, according to Hale.
Hospitals will be forced to come to a point when they look at what post-acute option will be the most economical as well as most effective — a skilled nursing stay or home health services; inpatient rehabilitation vs. rehab at a skilled nursing facility, she says.
Medicare spending per beneficiary does not change the fact that patients have freedom of choice about post-acute providers, Lloyd adds. "Case managers, physicians and others working with the family can provide additional quality information about providers or can use risk assessment tools to determine where patients should be placed, but that doesn’t change the fact that beneficiaries get to choose where they go," Lloyd says.
CMS’ emphasis on the entire episode of care should encourage more relationship-building across care settings and more collaboration across provider types, Lloyd says.
In order to succeed under value-based purchasing, hospital staff members must work together as a team to develop a discharge plan that takes the patient’s medical and psychosocial needs into account and then collaborate with the providers at other levels of care to ensure that the plan succeeds, Lloyd says.
