Compliance issues create extra work for hospital discharge planners
Compliance issues create extra work for hospital discharge planners
Study shows hospitals likely to keep patients in group
Some laws and regulations approved in the last several years have forced discharge planners to shift part of their focus from the patient to government compliance.
Since the Balanced Budget Act of 1997 took effect, discharge planners and other hospital staff have become bogged down with added paperwork and fat documents full of new and often cumbersome regulations to follow.
One such regulation dramatically affecting discharge planning is patient freedom of choice. Basically, the rule requires that hospital discharge planners provide Medicare patients needing home health care with a list of certified facilities so that the patients can choose their own postacute care rather than automatically being sent to a facility owned by the hospital. In order to be placed on the list, a home health agency (HHA) must make a request, have Medicare certification, and service the area.
"The first goal of patient freedom of choice is
to empower patients, and the second goal is to decrease perceived overutilization when hospitals refer to captive health care providers," said Vicki Myckowiak, JD, of the Detroit law firm Myckowiak Associates, PC, when she spoke at the 5th Annual Hospital Case Management Conference in Atlanta earlier this year. A hospital cannot limit the number of providers on the list, she says. "If they request to be on the list and they fit the criteria, you have to put them on it."
Though the regulations may have been well-intended, they often cause extra work and headaches for someone down the line, says Jackie Birmingham, RN, MS, vice president of Hartford, CT-based E-Discharge. Birmingham says that before the patient choice rule went into effect, discharge planners were as fair as they could be in advising patients on home health facilities. "It is just a matter of professional practice," she says. "I don’t think it is good business to keep them in your system if there is another quality facility that could take care of them."
It may not be good business, but a study released in December 1997 by the Office of Inspector General proves that prior to implementation of the new rule, patients were more likely to be referred to postacute care in a hospital-owned facility.
According to a study of discharge planners nationwide, 62% of patients were transferred to agencies owned by the discharging hospital, and 38% of those who went to the hospital-owned HHA say the hospital sent home care people to them.
Also, 19% of discharge planners reported that unless the family or patient objected, they referred all patients to the hospital-owned HHA. The study also shows that 10% of discharge planners believed that someone from the hospital actually put pressure on the patient to choose a particular HHA. (See related story in Hospital Case Management, September 1998, pp. 169-172.)
The length of stay in the hospital was not influenced by whether the patient was transferred to a captive or independent HHA. However, patients receiving care from a hospital-owned HHA averaged 49 days of service vs. 37 days for an independent HHA.
"What you have essentially is a government study that is saying that when you refer patients to captive providers for post-hospital services, it costs the government more money, and the lengths of stay are increased in the post-hospital providers," Myckowiak says.
"There have been a lot of recommendations. The first and probably the scariest was that they say we really ought to be going out and looking at hospitals that are having increased LOS and see whether they are trying to move patients out just to increase their reimbursement. Although I haven’t seen that happen in great numbers, it is something that the government may revisit in the future as the focus comes back to this issue," she says.
Medicare conditions of participation require that hospitals have a discharge planning process in place and that the process provides freedom of choice to patients and their families, Myckowiak says. Freedom of choice is not limited to Medicare patients; it applies to all patients. Non-Medicare patients should have an opportunity to view the HHA list, but should be aware that there could be a financial responsibility with some facilities.
Myckowiak says hospitals are not required to actively search out HHAs to be included on the list. If a hospital’s plan is working well, the HHAs will contact the hospital and request to be listed and also will contact the hospital if the facility closes or loses its Medicare certification.
"The rule states that each hospital has to provide a list of Medicare-certified home health agencies if they request to be placed on the list," says Diane White, MSN, BSN, MEd, vice president of clinical services for Visiting Nurse and Hospice Services in Kalamazoo, MI. "But it is not the [HHA’s] responsibility to keep the hospital informed if it has a change in service. It is the hospital’s responsibility to update its list and check back with the facility.
"The regulation does not say that you have to update the list," White notes. "But a good hospital will."
If the list ends up being seven pages with more than 100 facilities, as such lists often do, there’s nothing the hospital can do about it, except continue to update it, Myckowiak says. (See related story, this page.)
Also required on the list is disclosure of a hospital’s financial interest or ownership of any facilities included.
Every discharge planner knows that eventually she will come across a patient or family who cannot make a decision about which HHA to select.
"When patients say they just don’t know, we can tell them there are certain facilities owned by our hospitals and there are the phone numbers," Myckowiak says. "We’ve got the law, but we’ve also got ethics and our consciences too. When a patient asks about the quality of care of [your] provider, it is accurate and factual to tell them the truth. But what you don’t want to do is tell them that your facility is the best and you would only recommend your facility."
Then there’s the question of a hospital’s responsibility if a patient receives poor care and returns to the hospital and tries to sue. To avoid that, Myckowiak recommends that hospitals put a disclaimer on the list saying they don’t endorse any facilities.
(Editor’s note: To read the full report on Patient Freedom of Choice, visit the Office of Inspector General’s Web site at www.dhhs.gov.)
For more information, contact:
Vicki Myckowiak, JD, principal, Myckowiak Associates, PC, Detroit. Telephone: (313) 963-1002.
Jackie Birmingham, RN, MS, vice president,
E-Discharge, Hartford, CT. World Wide Web: www. lhm.com.
Diane White, MSN, BSN, MEd, vice president of clinical services, Visiting Nurse and Hospice Services, Kalamazoo, MI. Telephone: (616) 343-1396.
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