CMS mandates better DP earlier in the stay
Take time to find out what’s up with patients
The discharge planning worksheet that surveyors will use to assess hospitals’ compliance with Medicare Conditions of Participation highlights the need for case managers to be more proactive in discharge planning and identifying the right post-acute setting in a timely fashion, says Laura Jacquin, RN, MBA, managing director for Huron Healthcare, a Chicago-based consulting firm.
"Case managers should be doing better planning earlier in the stay," she adds. She recommends that case managers screen all patients for high risk factors at the time of admission. Look at age, diagnosis, mental status, comorbidities, polypharmacy issues, financial or social challenges, potential living arrangements and support after discharge, understanding of the disease process and medication regimen, and what post-discharge care they will need, she says.
"You want to make sure the surveyors see that all these questions are built into your assessment process and that case managers spend the time it takes to ask them," she says.
People who are doing discharge planning should take an in-depth look at patients’ abilities to manage in the place to which they will be discharged and ask the right questions to determine if they can be compliant in that environment, adds Michele Kala, RN, MS, surveyor for the Healthcare Facilities Accreditation Program.
It’s not enough to pop in, check off the boxes for a three-minute questionnaire, and arrange services. Discharge planners have to assess the patient’s ability to be compliant and put them in the best environment to make it happen, she says.
When case managers perform a discharge evaluation, they should include an assessment of whether the patient can go back to where he or she was before admission, says Jackie Birmingham, RN, BSN, MS, CMAC, vice president emerita of clinical leadership for Curaspan Health Group, a transition management software company based in Newton, MA.
"The Centers for Medicare & Medicaid Services (CMS) doesn’t want hospitals to just send patients back to the same level of care. If a patient meets acute care admission criteria, they are very sick and something in their care plan has to change. CMS wants discharge planners to pay more attention to assessing patients for continuing care needs," she says.
It’s logical to assess patients differently depending on where they came from, Birmingham says. "Patients who came from a skilled nursing facility may have different reasons for the admission than patients who came from the home environment. Case managers need to drill down and find out why patients were admitted," Birmingham says.
Look at the whole gamut of care patients have been receiving and collaborate with the attending physicians to decide where they should go next based on where they came from, Birmingham says.
One of the big holes in the discharge planning process is the lack of communication between nursing and case management, Birmingham says. "When nurses complete the initial assessment, they know which patients are likely to have complex needs and they should alert case management," she says.
John Laursen, managing director for Huron Healthcare, suggests daily patient progression rounds during which the entire care team gets together and talks about every patient. "The discussions can be as short as 30 seconds for some patients but should include the patient’s condition, discharge disposition, and the plan for the day. These meetings allow the care team to get on the same page," he says.
"I’m seeing more and more hospitals investing resources in interdisciplinary walking rounds where the staff talk about each patient and their discharge needs. Communication is phenomenal during these rounds, and everybody gets a discharge plan," Kala adds.
Discharge planners should interact with patients and get their input on the discharge plan, says Sue Dill Calloway, RN, MSN, JD, CPHRM, CCM, CCP, president of Patient Safety Education and Consulting in Dublin, OH. "You can’t just produce a discharge plan and hand it to patients. You need to talk to them about the plan and ask them to repeat it. There are 90 million Americans with low health literacy. Discharge planners need to make sure they understand what they are supposed to do," Dill Calloway says. She adds that English is not the primary language for 50 million Americans, so hospitals should use interpreters as needed.
She suggests that case managers make an appointment for a patient to see his or her primary care provider after discharge. "The timing is critical. One study has shown that readmissions were reduced if the patient has a follow-up appointment within one to four days after discharge," she says.
There are some patients who are going to be noncompliant no matter what you do, Kala points out. "But most patients don’t want to be noncompliant. They just don’t have what they need to follow their discharge plan. It’s a matter of flushing out all the issues and determining the best post-discharge setting and finding the resources they need," she says.