Medicare Conditions of Participation require discharge pros

Discharge expert shares interpretation of rules

Interpretation of the final rules for hospital participation in Medicare and Medicaid -- which became effective in 1995 -- is still ongoing, but discharge planners and case managers struggling to determine the effect of those rules can count on one certainty: Hospitals will always need specially designated discharge planning staff to manage programs that meet legislative standards.

So says Jackie Birmingham, RN, MS, A-CCC, director of continuity of care for Chartwell Home Therapies in Waltham, MA, and past president of the American Association for Continuity of Care in Hartford, CT.

"Some hospitals have integrated discharge planning into the role of other health care professionals," Birmingham adds. "That may work for a lot of patients, but there are always going to be those who need extra concentration. Hospitals must balance their need to decentralize services to cut costs with the need for a centralized discharge planning department."

To provide proper discharge planning for the estimated 20% of patients who don't fit into a standard care plan or who stray from the critical path, hospital discharge planning programs need professional, dedicated coordinators to perform at least the following functions, Birmingham says.

* Provide direct care coordination needed to achieve a timely and safe transition to post-hospital care for patients who are likely to suffer adverse health consequences if discharged without adequate discharge planning.

* Develop a list of alternate care programs and services that can be used as a resource tool for all staff providing discharge planning.

* Provide expert consultation to other staff to assure that discharge planning is part of any overall plan of care for hospitalized patients.

* Provide education to those staff who do discharge planning and need information on the clinical and social factors that affect functional status at discharge.

* Write, implement, and evaluate policies and procedures that address continuity of care needs and discharge planning processes for the institution.

* Participate in evaluation projects that identify outcomes of care, and participate in research activities aimed at improving continuity of care.

Birmingham points out that in the Social Security Act, the discharge planning process is explained as follows: "To assure the coordination needed to achieve a timely transition to post-hospital care, discharge planning is necessary. It enables a hospital and patient to arrange for services that do not need to be furnished in an inpatient hospital setting."

The Condition of Participation for Discharge Planning, as contained in the Social Security Act (and published in the Federal Register/Dec. 13, 1994), is divided into five general standards:

* identification of patients in need of evaluation;

* the evaluation process;

* the discharge plan;

* referral or transfer of the patient, along with the necessary medical information;

* ongoing reassessment of the discharge planning process to ensure that discharge plans meet individual patients' needs.

Concerns on following the conditions

In response to concerns and questions about adhering to the conditions of participation in daily practice, Birmingham has developed some informal interpretations and guidelines for discharge planners and case managers. She notes that she has confirmed the accuracy of her proposed "answers" to a variety of discharge planning questions with personnel at the Baltimore-based Health Care Financing Administration (HCFA).

Here are some excerpts from Birmingham's interpretations of the conditions of participation, as shared with Discharge Planning Advisor:

* To whom do the rules apply?

The rules apply to all patients admitted to a hospital that receives Medicare or Medicaid money, regardless of the patient's payment source.

* Who is a patient representative?

A patient's representative is any properly authorized "person acting on the patient's behalf." How to determine whether someone has been authorized to act on the patient's behalf, as there may be disputes concerning post-hospital care, is best left to the hospital and physician, who can handle those disputes within the limits of an applicable state law.

* How will patients know about these rules?

Hospitals do not need to specifically inform patients of the availability of discharge planning, since this information is included in the mandatory notice, "An Important Message From Medicare."

* Do there need to be written policies and procedures for discharge planning?

Yes. There is a requirement that the hospital commit its discharge planning policies to writing. Who, or which department, will be responsible for this facet of the overall program is not stipulated in the conditions. Not only is there a need for the written policies and procedures, but there must be a mechanism to assure that the policies are known by all staff, and that they are followed and updated as needed.

* How and when should patients be identified as needing discharge planning?

There is no specific time frame on when to identify patients. HCFA notes, "In some difficult situations, the plan may not be ready until shortly before the patient is discharged; having the plan ready too long before discharge does not allow for changing circumstances."

* Do these rules apply to patients being treated in an emergency department?

No. The condition supposes admission to hospitals and therefore does not apply to patients who receive care in a hospital emergency department and are not admitted. The Emergency Medical Transfer and Active Labor Act (EMTALA) covers discharges from emergency departments.

* Who should be responsible for discharge planning in a hospital?

Hospitals are allowed to determine the appropriate personnel to carry out discharge planning. It is stated that "a registered nurse, social worker, or other appropriate personnel must develop and supervise the development of the evaluation and discharge plan." Medicare surveyors will look at the education and experience of staff responsible for discharge planning.

* Should professional staff have additional training in discharge planning?

In response to comments that registered nurses and social workers should have additional training or credentialing, HCFA notes that the existing training and credentialing that those professionals receive is sufficient for discharge planning, and "we see no need to impose further requirements."

* Should discharge planning be assigned to a specific department in a hospital?

Not necessarily. The conditions permit "maximum flexibility" in hospital administration regarding this issue.

* Does the hospital need to keep a list of community care agencies?

Yes. The regulation requires hospital discharge planning personnel to maintain a complete and accurate compilation of information on community long-term care services and facilities for advising patients and their representatives of their options.

* Do patients have a choice in selecting a provider of post-hospital services?

Yes. Section 1802 of the Social Security Act guarantees free choice by Medicare patients. It provides that any individual entitled to Medicare may obtain health services from any institution, agency, or person qualified to participate under Medicare law if the institution, agency, or person undertakes to provide him or her those services.

* Does the hospital need to implement a plan for a patient before he or she is discharged?

Yes. The regulations published in this final rule require the hospital to arrange for the initial implementation of the patient's discharge plan prior to discharge. Previously, regulations required the hospital to assist in the plan; they now require the hospital to implement the plan.

* Does the physician need to request a discharge planning evaluation?

Not necessarily. The conditions state that an evaluation must be done at the request of a physician. This does not mean, however, that the evaluation only be done at the request of the physician. This means that even if the patient is not identified as needing a discharge planning evaluation, the physician may still request an evaluation.

* Should the discharge plan be in writing for the patient?

It is not a requirement of these conditions to furnish a written discharge plan for a patient; to require the patient or representative to sign the discharge plan to acknowledge receipt and participation in the plan; or, to require the hospital to document in the medical record that the patient and family have been counseled. Many states have enacted legislation to address those issues.

* Should the discharge plan be included in the medical record?

Yes. Surveyors will look at whether the hospital developed discharge plans for patients who needed them and whether the hospital arranged for the initial implementation of the plan. The hospital will be expected to document its decision about the need for a plan, document the existence of plans where they are needed, and show what steps it took to implement those plans initially. The review of the patient's medical record will be used to determine the appropriateness of the discharge plan and for evidence that all the standards are met.

As to whether a separate and distinct discharge planning form should be a mandatory part of the medical record, HCFA's response was that requiring this in all cases would not serve a useful purpose.

* What information needs to be transferred with the patient?

The regulations do not imply that the transfer of medical information includes copies of the original medical record. Information that must be transferred along with the patient includes:

-- a summary of the functional capacity of the patient;

-- the nursing and other care requirements of the patient;

-- a discharge summary and appropriate referral forms.

* How much family and/or caregiver involvement is expected?

One commentator thought that the overutilization of family caregiving systems should be avoided and that there should be more use of non-family-based community resources. HCFA's response: "Use of family caregivers occurs in discharge planning only when the family is both willing and able to perform needed services. In the absence of such a commitment, it is appropriate to use community resources that are not family-based."

* What is the requirement for specialized instructions for caregivers?

If part of the plan of post-hospital care of a patient includes that the caregiver give specialized care, such as wound care, administering IV medications, or monitoring blood glucose levels, there must be evidence of plans made for the caregiver to learn the care. HCFA notes that more specific information on the role of the caregiver will be included in the interpretive guidelines.

* How and when should patients be "reassessed"?

A part of the regulation was modified to "require reassessments on an as-needed basis, based on factors that may affect continuing care needs or the appropriateness of the discharge plan." However, HCFA does not agree that the regulation needs to specify that the reassessment be done before discharge.

Some factors that will be included in the interpretive guidelines for reassessment will include assuring:

-- the effectiveness of the identification criteria;

-- the quality and timeliness of discharge planning evaluations and discharge plans;

-- that the hospital discharge personnel maintain complete and accurate information on community long-term care services and facilities, and use this information to advise patients and their representatives of appropriate options;

-- that the hospital has a coordinated discharge planning process that integrates discharge planning with other functional departments, including the quality assurance and utilization review activities of the institution, and involves the various disciplines responsible for patient care.

* What happens if a patient refuses discharge planning services?

HCFA says, "As with other services offered by hospitals, patients may refuse to accept discharge planning or to comply with a discharge plan, just as they may refuse medical treatment. When a patient exercises this choice, however, we suggest that the hospital document the patient's refusal."

[Editor's note: Jackie Birmingham, the director of continuity of care for Chartwell Home Therapies in Waltham, MA, and a past president of the American Association for Continuity of Care, can be reached at Chartwell Home Therapies, 429A Hayden Station Road, Windsor, CT 06095. Telephone: (860) 688-1511.] *