Reaching out to post-acute providers

Work with them to prevent readmissions

It’s no longer enough for case managers to create a discharge plan and forget about the patient as soon as he or she is out the door, advises Jackie Birmingham, RN, BSN, MS, CMAC, vice president emerita of clinical leadership for Curaspan Health Group, a Newton, MA-based transition management software company.

"The hospital is just one part of the continuum of care. Case managers need to have a focused commitment to ensure that patients succeed after they leave the hospital," she says.

Making sure that post-acute providers have what they need to care for patients is an integral part of the newest version of the Centers for Medicare & Medicaid Services’ discharge planning worksheets that surveyors will use to assess compliance with the Medicare Conditions of Participation, according to Sue Dill Calloway, RN, MSN, JD, CPHRM, CCM, CCP, president of Patient Safety Education and Consulting in Dublin, OH.

When patients are transferred, the transfer form must include a brief reason for hospitalization, the course of treatment, the patient’s condition at discharge, a medication list, allergies, pending laboratory work, and a copy of the advance directives. "These items are mandatory, not optional," she says.

Surveyors will check to ensure that the discharge summary was sent to the patient’s primary care physician before the first follow-up visit or within seven days of discharge if no follow-up appointment was made, Dill Calloway says."Case managers should document the appointment for the follow-up visit and make sure that the discharge summary gets into the hands of the primary care provider. Hospitals need to do this even though it is a blue box advisory,’ which means it is highly recommended but the surveyor won’t cite the hospital if it isn’t done. This process is important to prevent unnecessary readmissions, which cost hospitals with a higher-than-average readmission rate $217 million dollars this year," she says.

Hospitals need to communicate regularly with staff from post-acute facilities to make sure they are receiving the information they need to care for patients at the next level of care in a timely fashion when patients transition, Dill Calloway says.

"Hospitals are trying to find creative ways of getting this kind of information without making it problematic. Some send out questionnaires. At other facilities, the case managers contact the post-acute providers for feedback. Others have regular meetings with the post-acute providers to talk about what could be done differently," says Michele Kala, RN, MS, a surveyor for the Chicago-based Healthcare Facilities Accreditation Program.

The Conditions of Participation also mandate that hospitals analyze their 30-day readmissions to find the cause and determine what could have been done to avoid the readmission. If hospitals do not track their readmissions as part of discharge planning, they will be cited, Dill Calloway says.

A more introspective look

The surveyors also will look to see if the hospital made changes to the planning process as a result of potentially preventable readmissions. "CMS wants hospitals to take a more introspective look at the causes for potentially avoidable readmissions and to make changes to improve their processes," Kala says.

When patients are readmitted for the same condition within 30 days, find out why. For instance, don’t just look at whether the patient got the prescription filled; drill down to find out if the patient was taking the medication as prescribed, Kala suggests. Then give patients the resources they need to follow their plan.

Kala tells of one hospital that interviewed patients readmitted with heart failure and found that a sizable number of patients weren’t weighing themselves because they didn’t have scales. "The solution was simple: The hospital starting giving heart failure patients digital scales," she says.