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It’s the law, but no one’s looking yet
Discharge planners at some facilities apparently are either unaware of — or are ignoring — a federal requirement that hospitals offer patients a choice of home care providers and that they tell patients when there is a financial interest between the hospital and an agency to which the patient is being referred.
Despite clear provisions to that effect under the Balanced Budget Act (BBA) of 1997, several sources say they are aware of hospitals that routinely refer patients to an affiliated home health agency for care, without either mentioning the other providers that are available or disclosing the connection between agency and hospital. At the other end of the spectrum, are hospitals that have a clear, proactive policy in place for ensuring that patients are aware of their home care options.
Repercussions to come?
The good news for noncompliant hospitals is that repercussions aren’t likely to be felt until at least sometime next year, which looks to be the soonest that any type of monitoring process could be in place. "We had so many provisions [of BBA] to implement that it’s taken a long time catching up with all of them," according to a spokesman from the Centers for Medicare & Medicaid Services (CMS). No further action has been taken following the publication of a proposed rule in the Nov. 22, 2002, Federal Register, he says. The comment period ended Jan. 21, 2003.
"A draft version of the final regulation is in the clearance process here," the spokesman adds, but he says the rule then will have to be cleared by the Department of Health and Human Services (HHS) and the Office of Management and Budget (OMB). It’s not uncommon for just the OMB piece of the process to take 90 days, he explains.
The interest and concerns expressed by the home care industry in CMS’s Open Door Forums provided the impetus for the rule-making process, the spokesman says. Once the rule is in place, he notes, hospitals will be required to begin submitting data on their post-acute care referrals and will be monitored on their actions.
That day can’t come soon enough for Ann Bender, MHA, RNC, CMC, owner, president, and CEO of Private Care Resources Inc., in Duncansville, PA. "[Discharge planners] need to realize there is a requirement there to offer options to the patient," she says. Bender, whose company provides home care services, says she experienced the situation firsthand when her mother was hospitalized in 2002. First, Bender says, she had to cancel arrangements that had been made to have home health care provided by the hospital-affiliated agency. Then, when she arrived to pick up her mother, she learned the equipment needed had been ordered from the durable medical equipment (DME) company connected with the hospital, she continues. "I said, Who made the choice?’ and the nurse said, We thought it would be convenient.’"
When the nurse didn’t seem to understand the reason for her concern, Bender says, she decided to handle the matter after getting her mother home. "I called the DME company and said, Come get your stuff,’ and then I called the company I wanted."
Section 4321 of the BBA, Nondiscrimination in Post-Hospital Referral to Home Health Agencies and Other Entities, paragraph (a), Notification of Availability of Home Health Agencies and Other Entities as Part of Discharge Planning Process, has four requirements:
1. Hospital staff must provide patients referred for home health with a list of agencies available in the area where patients reside (Pub. No.105-33, Sec. 4321, 111 Stat. 394, 1997).
2. Agencies formally must request each hospital to list them as available for service delivery.
3. Hospitals may not specify or otherwise limit qualified agency providers.
4. Hospitals must tell a patient when there is a financial interest between the hospital and agency if the patient is referred to that agency.
In the case of the hospital she dealt with, says Bender, "I’m sure [the nurses handling the discharge] are not aware [of the federal requirement]. Their directive is, You refer to our own.’" Patients leaving the hospital, meanwhile, often are not in the best frame of mind to take a proactive approach in arranging their care, she says, and may say something such as, "Who do you think I should use? Just set it up."
In contrast to the hospital Bender describes, discharge planners at Mt. Ascutney Hospital and Health Center in Windsor, VT — and throughout that state — with the best intentions of following the BBA directive find themselves facing an unusual challenge.
The state of Vermont requires all home care services to be offered through local Visiting Nurse Agencies (VNA), with the aim of providing quality care to all levels of need, regardless of insurance status, explains Cheryl Briere, RN, CCM, director of case management at Mt. Ascutney. As a result, there is no choice for patients who require home care services. "Every state may have different regulations" concerning home care, she points out. Neighboring New Hampshire, where Briere worked for most of the past 10 years, "is totally different," she adds. "It allows for-profit nurse staffing agencies to compete with the VNA, giving patients several choices for home care services."
The particular difficulty Vermont discharge planners face, Briere says, stems from two things: "The patients being discharged are more complex than ever before, and due to staffing shortages, the VNA often is unable to offer as much care as might be requested." As part of a quality improvement process, she adds, Mt. Ascutney case managers have been making follow-up telephone calls to patients within a few days of discharge to determine if home care services have been initiated. "We have cases in which the patient does not receive services within the appropriate time," Briere notes. "If we order physical therapy three times a week, we get it two times a week."
Her department is wrapping up six months of data collection, she says, and will sit down with VNA representatives to identify problem areas and possible solutions. Further complicating care delivery, she says, is the rural nature of the state. "It often takes two hours to get to somebody’s house. "If care is not available, and if there is no choice," Briere adds, "how do you advocate for the patient for the appropriate level of care?" As for other post-acute services — such as intravenous infusion and chemotherapy or total parental nutrition — Mt. Ascutney case managers are able to offer some choice to patients, she says, although nursing services associated with these therapies still must be delivered by the local VNA.
"We say, Here are your choices,’" she notes, "and if the patient doesn’t have a preference, we can offer suggestions, can say, We had great success with this company,’ because there are those that provide better service for a particular item and still meet the criteria for patient choice."
To ensure its compliance with the BBA regulation, Briere says, Mt. Ascutney already has implemented a policy and procedure for post-acute care referrals. Patients are given a list of available vendors from which to select and are asked to sign a document saying they’ve been given that choice, she adds.
A small, rural critical access hospital with a rehabilitation unit as well as acute care beds, Mt. Ascutney finds itself on the other side of the referral equation, Briere points out, when an area hospital refers patients to its rehab unit. "As a critical access hospital, we’re allowed to have a total of 25 beds and no more than 15 acute care beds, so we can bring in rehab patients to fill in the difference," she explains. Because of the hospital’s space constraints, Briere says, sometimes there is a backlog of referrals. That puts her in the position of reminding the referring hospital’s staff of the need to offer patients other rehab choices or, if appropriate, home care, she notes.
Supplying choices in an unbiased manner
At OSF Saint Anthony Medical Center in Rockford, IL, discharge planners offer the full range of post-acute care options to patients, explains Joyce Nicklas, RN, MBA, director of quality/care management. "When staff go in to interview patients [regarding post-discharge care], we just give them the names of all we’re aware of," Nicklas says. "We let them know there’s a choice, and ask them if there is an area — like a mileage range — that would be their first choice. Then we give them the list of agencies that are in that radius," she adds.
The home care agencies are in alphabetical order, Nicklas notes, which means the hospital-affiliated agency, the name of which begins with "OSF," is far down the list. "We tell them up front it is affiliated with the hospital but that they have no obligation to use it."
To keep the process objective, Nicklas says, patients are asked what they are looking for in a home care provider, and are encouraged to check agency web sites and rankings given by the Chicago Sun-Times and other entities. "We also tell them to talk to their physician, so we’re not imposing [our views]," she adds.
The process is so evenhanded, Nicklas says, that the affiliated agency — far from having the majority of hospital referrals — gives the feedback that it isn’t receiving very many patients from that source. When hospitals fail to abide by the BBA rules, she suggests, it may have to do with the discipline that is handling the process, as well as with a lack of training. Social workers — who coordinate referrals at Saint Anthony’s — tend to be more in tune with such directives than are nurses, Nicklas says.
"At some hospitals, what they call case management — and the training that goes into it — is so varied," she points out. "A general staff nurse or someone who has not worked on the case management side of things may not be aware that [the BBA directive] is out there."