Hospitals: Beef up discharge planning
CMS: Same-day surgery patients may need planning
As the Centers for Medicare & Medicaid Services (CMS) continues its emphasis on discharge planning, it’s more important than ever to create a comprehensive discharge plan that provides everything patients need to manage in the next level of care, some experts say.
Beginning this year, surveyors will use a discharge planning worksheet to review how hospitals comply with the discharge planning portions of the Medicare Conditions of Participation (CoPs). As part of its Patient Safety Initiative, CMS has also developed worksheets to help surveyors assess compliance with the CoPs for performance improvement and infection control. The worksheets are designed to assist the surveyors and the hospital staff to identify when they are in compliance.
CMS came out with the final revised worksheet for discharge planning in March, according to Sue Dill Calloway, RN, MSN, JD, CPHRM, CCM, CCP, president of Patient Safety Education and Consulting in Dublin, OH. Surveyors will use the worksheet whenever a CMS survey is done.
The discharge planning survey worksheet gives hospitals a step-by-step guide to what CMS expects hospitals to be doing to comply with the CoPs, but it also is a blueprint for what hospitals should be doing anyway, says Laura Jacquin, RN, MBA, former managing director for Huron Healthcare, a Chicago-based consulting firm. "The Conditions of Participation are patient-focused, patient-centric rules that spell out the right thing to do for patients. They are very much focused on providing an effective, comprehensive discharge plan with patient safety and preventing readmissions in mind," Jacquin says.
Hospitals must have discharge planning policies and procedures in writing, but it’s not enough to just have them in place; you have to be able to follow them and show that you have done so, adds John Laursen, managing director for Huron Healthcare. "The challenges we see as we work with clients is operationalizing the policies on a day-to-day basis," he says. "Case managers and the entire care team need to work together."
The surveyors will be reviewing hospitals’ discharge policies and procedures to determine if they meet all the requirements of the CoPs and if they are in effect for all inpatients, not just Medicare patients, Jacquin says. They will look for evidence of discharge planning activities on every unit and will determine if the staff are following the discharge planning policies and procedures.
The discharge planning policies originally were intended just for inpatients, but CMS has added three categories of patients who might need discharge planning. The worksheet has check-off boxes for discharge planning processes for same-day surgery patients, patients receiving observation services who are not subsequently admitted, and emergency department patients who are not subsequently admitted.
Dill Calloway suggests that hospitals put together a team to review the worksheet and complete it as a self-assessment to make sure they are doing everything that CMS requires. The discharge planning worksheet reflects the changes made in the CMS standards on discharge planning that went into effect on July 19, 2013. "CMS completely rewrote all of the discharge standards in a 39-page memo that decreased the number of standards from 24 to 13," she adds.
CMS now publishes quarterly deficiency reports that show that many hospitals are receiving deficiencies in the discharge planning standards, Dill Calloway says. In the January 2014 report, there were 364 deficiencies.
The key issue in compliance is identifying patients who are at high risk for readmission and developing a discharge plan to make sure that wherever they go after discharge, they will be able to manage in a safe manner and stay healthy, says Michele Kala, RN, MS, a surveyor for the Chicago-based Healthcare Facilities Accreditation Program (HFAP), which has deeming authority from CMS. "There are no specific criteria for hospitals to use to identify the high-risk population," Kala says. Hospitals with limited resources might not have the staff to conduct a discharge planning evaluation on every patient. In that case, they should come up with a mechanism to identify high-risk patients by diagnoses, severity of illness, and psychosocial needs, Kala says. "If facilities don’t have the resources to invest, it’s acceptable to Medicare to create a discharge plan only for patients who are at risk," she says.
The best practice for hospitals is to conduct a discharge planning evaluation on every patient, Dill Calloway adds. However, if you don’t evaluate every patient, your policies and procedures must include a process to notify patients, family members, and attending physicians that they can request one, even if the patient doesn’t meet high-risk criteria, she says.
The surveyors will look for a process to notify patients that they can request a discharge planning evaluation. Dill Calloway suggests that the information be included in the patient rights and responsibilities document and that patients be asked to sign it. The nurse also can inform the patient of his or her right to request an evaluation during the admission assessment and document it. "Don’t just hand the patients a sheet listing the patient rights," Dill Calloway says. "The best practice is for the registrar to give the patient the rights and responsibilities document at registration and go over the specific items."
How are physician educated?
Surveyors also will assess how physicians are educated on their right to request a discharge planning evaluation. Information on how to order an evaluation could be included in the new physician orientation manual, the chief medical officer could issue a memo to all physicians, or there could be a presentation at the medical executive committee meeting.
"This has to be done only if the hospital doesn’t perform a discharge planning evaluation on all patients," she adds.
Policies and procedures should specify when case managers or social workers are consulted, such as when patients have been admitted frequently, when the admission assessment indicates that the patient won’t be able to manage at home alone, or when patients have social issues, such as no place to live, Dill Calloway says.
The surveyors will review five patient records, including one who has a discharge planning evaluation with a discharge plan under development and, when possible, the record of a patient readmitted within 30 days.
The surveyors are going to pull charts and make sure that everything specified in the CoPs is happening, Jacquin says. "They will look to make sure the evaluation is done by a qualified professional who completes a comprehensive assessment. They will check to see that patients have a discharge plan and that the care team is communicating on a daily basis so that the plan is updated when the patient’s condition changes," she says.