Discharge planners help avoid COBRA violations

Looking at ‘big picture’ helps patient, hospital

While aware of the high stakes involved in COBRA violations, emergency department personnel many times don’t use a highly effective preventive tool at their disposal — their hospital’s discharge planners. Conversely, discharge planners aren’t taking the initiative in educating the harried and overworked ED staff about the important role the discharge planners can play.

"Discharge planners are often called to the ED, but not for the right cases," says Sharon Baschon, a utilization and case management consultant with the Baschon Group in Durham, NC. "Discharge planners know about COBRA [Consolidated Omnibus Budget Reconciliation Act], but since it’s based on medical screening or transfer, don’t perceive that they can have a role in it."

A hospital recently cited for a COBRA violation by the Baltimore-based Health Care Financing Administration (HCFA) provides a case in point, Baschon says.

The case involved an 89-year-old woman treated for a fractured wrist. The hospital was subsequently cited by federal investigators because it failed to do a full neurological exam.

Over the course of several visits to the ED, hospital personnel failed to follow up on several "risk screens" that would have been obvious to any competent discharge planner: The woman was frail and elderly, she lived in a personal care home, she exhibited signs of altered mental status, and she had multiple readmissions to the ED.

On the first visit, after the woman had fallen and fractured her wrist, Baschon points out, "No one seemed to ask the $64,000 question, ‘Why did she fall?’"

Had a discharge planner been called in on the case, he or she very likely would have recommended home health services for the woman, and would have gotten in touch with her primary care physician to discuss her situation, she says. By the second or third visit, the woman probably would have been put on observation status in the hospital as the discharge planner sought the best care option for her, Baschon suggests. "They would have realized that, obviously, where she’s living is not working out."

As it was, the woman was brought to the ED six times during a period of two weeks. She finally was brought in unconscious, and was later pronounced dead, with the preliminary cause of death documented as "left hip fracture, probable subdural hematoma and cardiovascular arrest," according to a HCFA Statement of Deficiencies and Plan of Correction dated April 1996.

A lot of EDs are missing the boat by not using a discharge planner to safeguard against such occurrences, Baschon says.

"If your hospital does not have a discharge planner based in the ED, the likelihood is that you have a real educational opportunity," she notes. "This is an opportunity for discharge planners to go to the ED and say, ‘These are the services we provide. We’re available in-house during these hours and 24 hours a day by pager.’"

But Baschon says she has found that just telling ED personnel that discharge planners are available is not enough. "Except on very traumatic cases, they won’t remember to call you unless they really get used to seeing you and talking to you."

She suggests doing random assessments, as a quality screen, of patients that are readmitted to the ED to identify those who would have benefited from discharge planning. That gives the discharge planner the opportunity to say, "We could have done this for this patient, and it would have been a better outcome," Baschon says.

"ED people don’t have time to do discharge planning," she adds. "If you do it, it’s a benefit for the patient."