Executive Summary
The Medicare Conditions of Participation require hospitals to give patients a choice of post-acute providers, but that doesn’t mean that case managers shouldn’t give them the information they need to make informed choices. Experts recommend the following:
- Give patients a list of providers that can meet their particular needs after discharge, but don’t steer them toward a provider in which your hospital has a financial interest.
- Start the discussion about the discharge destination early in the stay and give family members checklists that include what questions to ask and what to look for when they visit facilities.
- Be familiar with the post-acute providers in your area. Know the services they provide, their readmission rates, and how quickly they respond to a referral.
Arif Nazir, MD, was uncomfortable when he found out that one of the patients he had been treating in the hospital was being transferred to a particular nursing facility for post-acute care.
"I knew this was a complex patient, and I knew the nursing home had a doctor on the premises only once a week. The patient couldn’t receive the type of care he needed at this facility," says Nazir, a geriatrician who is associate clinical professor of medicine in the geriatric division at the Indiana University Medical School and an affiliated scientist at the Indiana University Center for Aging Research.
The patient’s case manager told him that the family chose the nursing facility because it was close to where they lived.
When he asked why someone didn’t educate the family on what would be an appropriate facility, the case manager replied, "We can’t influence their opinion because of Medicare regulations."
"Typically, hospitals provide a list of institutions and, because of misinterpretation of government regulations and lack of information on various facilities, don’t give advice. Families often have to make quick decisions and choose based on the location or physical attractiveness of the facility," Nazir says.
Hospitals may over-interpret the Medicare Conditions of Participation, Nazir says. "The regulations state that the selection of a post-discharge destination is a free choice. That does not absolve hospitals of the responsibility of providing unbiased assistance in the selection of the appropriate facility," he says.
If patients don’t get the care they need after discharge, it sometimes has a boomerang effect, Nazir adds. The patient goes to the skilled nursing facility, gets in trouble, and is readmitted to the hospital, then transferred back to the nursing facility and back to the hospital again. Every time the patient transitions from one facility to another, information gets lost and there is the potential for medical errors, he says.
"If the family makes a bad decision in selecting a facility, a lot of money is wasted and the patient may lose his or her independence," he says.
When discharge planning is not done properly and is done at the day of discharge, the services ordered may not be appropriate or they may not arrive, putting patients at risk for readmission to the hospital, emergency department visits, and poor health outcomes, says Toni Cesta, RN, PhD, FAAN, partner and consultant in Dallas-based Case Management Concepts.
In today’s world, hospitals have a lot at stake if patients don’t have a successful discharge.
In fiscal 2015, which began October 1, maximum penalties for hospitals with excess readmissions rose to 3% of all Medicare readmissions. Beginning this year, the Centers for Medicare and Medicaid Services has added hospital spending per beneficiary, also called hospital efficiency of care, to its Value-based Purchasing Program. Hospital scores are based on total Medicare expenditures in the time period from three days before admission to 30 days after discharge. The measure makes up 20% of a hospital’s value-based purchasing score in fiscal 2015 and will rise to 25% in 2016. And CMS has initiated the Bundled Payments for Care Improvement pilot program to test the cost effectiveness of paying a fixed price or lump sum for health services by multiple providers over a specified period of time or episode of care. (For details, see Hospital Case Management, October 2014, page 135.)
Case managers should be aware of the financial implications for their hospital if a discharge plan fails, but their focus should be on their patients, Cesta says. "Case managers have a legal and professional obligation to make sure their patients’ needs are met after discharge. If we do the right things for the patients, it will result in good outcomes," she says.
Hospitals are responsible and always have been responsible for developing an appropriate discharge plan and implementing the plan, says Elizabeth E. Hogue, Esq., a Washington, DC-based attorney specializing in healthcare issues. "There hasn’t been any change. The only difference now is that hospitals could lose money if the patient comes back within 30 days," Hogue says.
It may seem as if there’s a fine line between choosing for the patient and helping the patient choose, Hogue adds. "Freedom of choice means that case managers and discharge planners can give patients information to help them make informed decisions but the patients can reject the recommendations and choose anyone on the list they wish," she says.
"The Conditions of Participation for discharge planning are very clear, but people are still confused because they don’t read the Conditions of Participation," Cesta says. The requirements are for the choice list to include facilities within a geographic area requested by the patient that provide the services the patient needs, and that will accept the patient’s insurance coverage. The order of facilities on the list is up to you. You can put facilities that are affiliated with the hospital on the list, but you have to disclose that the hospital has a financial interest in the facility, Cesta says. Hospitals are required to give choice lists to patients who are being discharged to a skilled nursing facility or will receive home health services, she says.
If case managers just thrust a list at people, they often have difficulty choosing, Hogue points out. "Case managers are supposed to develop a discharge plan with the patient and family that includes pointing out appropriate providers who can implement the plan," she says.
Develop a discharge plan that everybody agrees on and then bring out the list. Say something like: "You have the right to choose any provider you want, but in terms of the discharge plan we developed together, these are the facilities that can implement that plan," Hogue suggests.
- Nazir A, Little M, Arling G. More than just location: Helping patients and families select an appropriate skilled nursing facility. Ann Longterm Care 2014;22: Issue 7-8. http://www.annalsoflongtermcare.com/print/2401
