Beef up your discharge planning processes, experts recommend
CMS surveyors will be checking for compliance
As the Centers for Medicare & Medicaid Services (CMS) continues its emphasis on discharge planning, it’s more important than ever for case managers to create a comprehensive discharge plan that provides everything patients need to manage in the next level of care, some experts say.
Beginning this year, surveyors will use a discharge planning worksheet to review how hospitals comply with the discharge planning portions of the Medicare Conditions of Participation. As part of its Patient Safety Initiative, CMS has also developed worksheets to help surveyors assess compliance with the Conditions of Participation for performance improvement and infection control. The worksheets are designed to assist the surveyors and the hospital staff to identify when they are in compliance.
CMS has been pilot-testing the worksheets since 2011, according to Sue Dill Calloway, RN, MSN, JD, CPHRM, CCM, CCP, president of Patient Safety Education and Consulting in Dublin, OH. CMS tested the third revised surveyor worksheet in 2013 and came out with the final revised worksheet for discharge planning in March 2014. Surveyors will use the worksheet whenever a CMS survey is done. The updated infection control and quality improvement worksheets are expected to be finished later this year.
"The worksheets are very important, and all hospitals that accept Medicare or Medicaid reimbursement should be intimately familiar with them," Dill Calloway says. "It doesn’t matter who accredits hospitals. They have to be in compliance with the CMS standards. Hospitals have to comply with the Medicare Conditions of Participation or they could be fined or lose their ability to bill for Medicare and Medicaid."
The discharge planning survey worksheet gives hospitals a step-by-step guide to what CMS expects hospitals to be doing to comply with the Conditions of Participation, but it also is a blueprint for what hospitals should be doing anyway, says Laura Jacquin, RN, MBA, managing director for Huron Healthcare, a Chicago-based consulting firm. "The Conditions of Participation are patient-focused, patient-centric rules that spell out the right thing to do for patients. They are very much focused on providing an effective, comprehensive discharge plan with patient safety and preventing readmissions in mind," she says.
Hospitals must have discharge planning policies and procedures in writing, but it’s not enough to just have them in place; you have to be able to follow them and show that you have done so, adds John Laursen, managing director for Huron Healthcare.
"The challenges we see as we work with clients is operationalizing the policies on a day-to-day basis. Case managers and the entire care team need to work together. Case management can’t work in isolation and expect to develop an effective discharge plan," he says.
The surveyors will be reviewing hospitals’ discharge policies and procedures to determine if they meet all the requirements of the Conditions of Participation and if they are in effect for all inpatients — not just Medicare patients, Jacquin says. They will look for evidence of discharge planning activities on every unit, and if the staff are following the discharge planning policies and procedures.
Dill Calloway suggests that hospitals put together a team to review all three worksheets and complete them as a self-assessment to make sure they are doing everything that CMS requires. The discharge planning worksheet reflects the changes made in the CMS standards on discharge planning that went into effect on July 19, 2013. "CMS completely rewrote all of the discharge standards in a 39-page memo that decreased the number of standards from 24 to 13," she adds.
CMS now publishes quarterly deficiency reports that show that many hospitals are receiving deficiencies in the discharge planning standards, Dill Calloway says. "In fact, in the January 2014 report, there were 364 deficiencies," she adds. (The deficiency reports are available at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Hospitals.html.)
"The worksheet is a good communication tool to ensure that everybody in the organization is knowledgeable about the discharge planning standards. Sometimes the questions in the worksheet are not apparent from a reading of the CMS hospital interpretive guidelines. It is very important for every nurse, social worker, and discharge planner to be familiar with the discharge planning standards and incorporate them into their staff education and their hospital’s policies and practices," she says.
The worksheet spells out what case managers should be assessing, says Michele Kala, RN, MS, a surveyor for the Chicago-based Healthcare Facilities Accreditation Program (HFAP), which has deeming authority from CMS.
"Case managers should be performing a complex assessment that covers everything a patient needs to be able to do in order to function in whatever setting they will be in after discharge. The assessment should spell out what the discharge planners need to do to modify the patient’s living environment or arrange community resources to support the patient’s medical needs," she says.
The key issue in compliance is identifying patients who are at high risk for readmission and developing a discharge plan to make sure that wherever they go after discharge, they will be able to manage in a safe manner and stay healthy and out of the hospital, Kala says. "There are no specific criteria for hospitals to use to identify the high-risk population. Case managers have to conduct a thorough assessment to identify patients who have complex problems and living situations that keep them from following their discharge plan," she adds.
Hospitals with limited resources may not have the staff to conduct a discharge planning evaluation on every patient. In that case, they should come up with a mechanism to identify high-risk patients by diagnoses, severity of illness, and psychosocial needs, Kala says. "If facilities don’t have the resources to invest, it’s acceptable to Medicare to create a discharge plan only for patients who are at risk," Kala says.
Jackie Birmingham, RN, BSN, MS, CMAC, vice president emerita of clinical leadership for Curaspan Health Group, a Newton, MA-based transition management software company, points out that in today’s healthcare environment, patients who are admitted to the hospital tend to be very sick and are being discharged earlier than ever. "If the inpatient admission criteria set says the acute care hospital is the only place for patients to be, they should be assessed to determine where they should go next," she says.
The best practice for hospitals is to conduct a discharge planning evaluation on every patient, Dill Calloway adds. But if you don’t evaluate every patient, your policies and procedures must include a process to notify patients, family members, and attending physicians that they can request one, even if the patient doesn’t meet high-risk criteria, she says.
The surveyors will look for a process to notify patients that they can request a discharge planning evaluation. Dill Calloway suggests that the information be included in the patient rights and responsibilities document and that the patients be asked to sign it. The nurse can also inform the patient of his or her right to request an evaluation during the admission assessment and document it.
"Don’t just hand the patients a sheet listing the patient rights. The best practice is for the registrar to give the patient the rights and responsibilities document at registration and go over the specific items," she says.
Surveyors also will be assessing how physicians are educated on their right to request a discharge planning evaluation. Information on how to order an evaluation could be included in the new physician orientation manual; the chief medical officer could issue a memo to all physicians, or there could be a presentation at the medical executive committee meeting.
"This has to be done only if the hospital doesn’t perform a discharge planning evaluation on all patients," she adds.
Policies and procedures should specify when case managers or social workers are consulted, such as when patients have been admitted frequently, when the admission assessment indicates that the patient won’t be able to manage at home alone, or when patients have social issues, such as no place to live, Dill Calloway says.
Your hospital should have a policy for updating changes in the condition of patients who were not immediately identified as needing a discharge plan. The surveyors will determine if the inpatient staff are aware of why and when and who should be notified if there is a change in a patient’s condition, according to Dill Calloway. For instance, if case management is called in only when the admission assessment indicates the need for a discharge plan, your policies and procedures should spell out what happens when there is a change in the patient’s condition or situation that warrants a discharge plan.
"When hospital case managers and nurse discharge planners see the patient or review their charts every day, this streamlines the process and ensures compliance. If this doesn’t happen, your policies need to specify how the discharge planner knows there is a change that means the patients do need a discharge plan," Dill Calloway says.
The discharge planning policies were originally intended for inpatients, but CMS has added three categories of patients who may need discharge planning. The worksheet has check-off boxes for discharge planning processes for patients receiving observation services who are not subsequently admitted, emergency department patients who are not subsequently admitted, and same-day surgery patients.
"Hospitals need to have a discharge planning policy in effect for all patients, not just those who are admitted as inpatients," Dill Calloway says.
The surveyors also will review five patient records, including one who has a discharge planning evaluation with a discharge plan under development, and when possible the record of a patient who was readmitted within 30 days.
The surveyors are going to pull charts and make sure that everything specified in the conditions of participation is happening, Jacquin says. "They will look to make sure the evaluation is done by a qualified professional who completes a comprehensive assessment. They will check to see that patients have a discharge plan and that the care team is communicating on a daily basis so that the plan is updated when the patient’s condition changes," she says.
When Kala conducts a survey for HFAP, she spends at least an hour with the discharge planning staff talking about the hospital’s discharge planning processes and going over the charts she has reviewed. "This is an educational session as well as a fact-finding meeting," she says.
- Jackie Birmingham, RN, BSN, MS, CMAC, vice president emerita of clinical leadership for Curaspan Health Group, Newton, MA. email:firstname.lastname@example.org.
- Sue Dill Calloway, RN, MSN, JD, CPHRM, CCM, CCP, president of Patient Safety Education and Consulting, Dublin, OH. email: email@example.com
- Laura Jacquin, RN, MBA, managing director for Huron Healthcare, Chicago. email: firstname.lastname@example.org.
- To order the CD of Sue Dill Calloway’s webinar "CMS Discharge Planning Worksheet 101" go to http://www.reliasmedia.com/public/products/CMS-Discharge-Planning-Worksheet-101.html