Centers for Medicare and Medicaid Services New Interpretative Guidelines for the Conditions of Participation for Discharge Planning Part 2
Toni Cesta, PhD, RN, FAAN
This month we are continuing with our two-part series on Medicare’s new guidelines for the Conditions of Participation (CoP) for discharge planning (www.cms.gov/cfcsandcops/).
Last month we began to review the guidelines, which were published by CMS in 2013. As we discussed, CMS provides the interpretive guidelines as a resource for case managers and discharge planners but also states that providers are not bound to them. So, as case managers, we should think of them as informational only. However, the guidelines can be very useful when questions arise as to the intent of some portion of the CoP for discharge planning. Case managers should find these guidelines helpful for this purpose.
Interpretive Guidelines for 482.43(c)(6)
This section discusses the hospital’s role in the discharge planning process for patients transitioning to a home health agency (HHA) or skilled nursing facility (SNF). This particular section has caused some confusion for case managers and discharge planners over the years, so I think it is important to quote the section here:
"The hospital must include in the discharge plan a list of HHAs or SNFs that are available to the patient, that are participating in the Medicare program, and that serve the geographic area (as defined by the HHA) in which the patient resides, or in the case of a SNF, in the geographic area requested by the patient. HHAs must request to be listed by the hospital as available."
As case managers, we are only required to give this list, sometimes referred to as the "choice list," to patients for whom home health or skilled nursing services are indicated and appropriate.
Managed care patients are handled slightly differently. The choice list given to patients participating in managed care plans must include those HHAs and SNFs that are available via a contract with the patient’s specific managed care organization.
Finally, the hospital must document that the list was presented to the patient or their representative in the medical record.
Interpretive Guidelines for Section 482.43(c)(7)
For discharge planners and case managers, the CoP is very specific about ensuring that the hospital informs the patient or the patient’s representative of the right to choose among participating Medicare providers of post-hospital services. Whenever possible, the hospital must respect the preferences of the patient and family when they are expressed. The hospital must not specify or limit the qualified providers that are available to the patient.
Interpretive Guidelines for Section 482.43(c)(8)
This section has to do with any HHAs or SNFs that your hospital may have a financial interest in, either through affiliation or ownership of such an entity. If there is such an affiliation or ownership, then you must disclose this information to the patient. Conversely, if an HHA or SNF has a financial interest in the hospital, the same disclosure would apply. If you are not sure whether your hospital has a financial interest in a particular entity, you can refer to the provisions of Part 420, Subpart C of this section.
Interpretive Guidelines for 482.43(c)(6), 482.43(c)7) and 482.43(c)(8)
As discussed above, this section continues to explain that the hospital must include a list of Medicare-participating home health agencies (HHAs) and skilled nursing facilities (SNFs) in the discharge plan for those patients whose discharge plan indicates that they will need these services after leaving the hospital.
Medicare defines extended care services in the following way. Your department should be sure to include this precise definition in its policies and procedures for discharge planning.
"Extended care services" are defined at sections 1861(h) and (i) of the Social Security Act as items or services furnished in a skilled nursing facility (SNF). SNFs included on the list must be located in a geographic area that the patient or patient’s representative indicated that he or she prefers.
For home health agencies (HHAs), the list must consist of Medicare participating HHAs that have requested the hospital to be listed and which serve the geographic area where the patient lives. Hospitals may expect the HHA to define its geographic service area when it submits its request to be listed.
While you are performing the discharge planning process, the hospital must inform the patient of his or her freedom to choose among Medicare-participating providers. As a discharge planner / case manager, you are not allowed to direct the patient to specific providers or otherwise limit which qualified providers the patient may choose from.
Hospitals may develop their own lists or print a list of skilled nursing facilities and home health agencies in the appropriate geographic areas from the CMS websites.
If your hospital does not have a list, you may want to access http://www.medicare.gov/nursinghomecompare/search.html for nursing homes and www.medicare.gov/homehealthcompare for home health agencies.
If your hospital does use its own list, it is expected to update the list at least annually (69 F 49226, August 11, 2004).
Other Information on Choice Lists
You may also want to refer your patients and families to the Nursing Home Compare and Home Health Compare websites for additional information on any of the Medicare participating home health agencies and nursing facilities.
If patients and families are interested in additional information, you can advise them that the Nursing Home Compare site includes overall performance ratings, characteristics of the nursing home, performance on quality measures, inspection results, and nursing staff information.
The Home Health Compare website provides details about every Medicare-certified home health agency in the country. Included on the website are quality indicators such as managing daily activities, managing pain and treating symptoms, treating wounds and preventing pressure sores, preventing harm, and preventing unplanned hospital care.
In addition to the resources cited above, there are others resources that you and your patients can access. You can refer the patient to individual state agency websites, the Long-Term Care Ombudsmen Program, protection and advocacy organizations, citizen advocacy groups, area agencies on aging, centers for independent living, and aging and disability resource centers. These agencies can provide additional information on long-term care facilities and other types of post-hospital care. Some patients and families may find this information helpful to them as they make decisions regarding post-acute care options.
CMS also guides you on how to manage patients enrolled in managed care plans. If your patient is enrolled in a managed care plan that utilizes a network of preferred providers, then the hospital must make every reasonable attempt to limit the list to those HHAs or SNFs that participate in the insurer’s network of providers. This list will be dependent on the information provided by the insurer in which the preferred providers are disclosed.
If your hospital has a financial interest in a home health agency or skilled nursing facility that is disclosable, then these facts must also be stated on the list provided to the patient. The hospital is required to know when disclosure is necessary and to comply with this requirement.
When the patient or family has expressed a preference, the hospital must make every attempt to arrange the post-discharge care with an HHA or SNF that meets these preferences. If this is not possible, due to bed availability or other reason, the hospital must document the reason(s) why the patient’s preference could not be fulfilled in the medical record. In addition, the reason must be explained to the patient. The case manager should document this conversation in the medical record as well.
Standard 482.43(d): Transfer or Referral
This standard states the following: "The hospital must transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care."
Interpretive Guidelines 482.43(d)
The intent of this standard is to ensure that patients receive appropriate post-hospital care and that this care is arranged, as applicable, to include transfer to appropriate facilities or referrals to follow-up ambulatory care services.
Appropriate facilities, agencies or outpatient services refer to entities such as skilled nursing facilities, nursing facilities, health home agencies, hospice agencies, mental health agencies, dialysis centers, suppliers of durable medical equipment, suppliers of physical and occupational therapy, physician’s offices, etc., which offer post-acute services as needed by the patient and identified in the discharge plan. Although this does not include non-healthcare entities, hospitals are still encouraged to make appropriate referrals to community-based resources that may offer transportation, meal preparation, and any other services that may play a role in the positive recovery of your patient. CMS also stipulates that appropriate facilities may also include other hospitals to which the patient is transferred for follow-up care, such as rehabilitation hospitals, long-term care hospitals, or even other short-term acute care hospitals.
Transfer of Paperwork
As discharge planners, case managers must also ensure that the proper paperwork is provided for patients being transferred or discharged home with services. In addition, case managers are required to inform the patient’s physician of the outcome of the hospital treatment and the patient’s follow-up care needs. This can be accomplished through an electronic medical record summary and/or a phone call to that physician. Electronic communication is always preferred as it is more likely to be done automatically and timely.
As case managers, we must always consider the continuum of care in our communication around discharge planning activities. As the health care environment continues to change, we must remain aware of the community-based providers caring for our patients as they are discharged back into the community. If your hospital uses a hospitalist model, this is even more important. The community-based physician needs to be informed as to the outcomes of the hospital care and the post-hospital care arrangements that may have been made. In a hospitalist model, it is conceivable that the patient’s physician may have had no interaction with the patient throughout the course of the hospital stay.
Information can be exchanged during these interactions, some of which can help to facilitate a reduction in readmissions or unnecessary visits to the emergency department. This might include changes to the patient’s pre-admission medication regimen or other elements of the post-discharge plan that the community-based physician should know about. So, in addition to electronic transfer of information, a verbal hand-off of information should also take place.
The CoP recommends the following medical information to be included. You may want to consider hardwiring this process through the use of a "case management transfer summary form." In this way, you can ensure that the same, standardized information is passed every time a patient leaves the hospital.
Medical Information for Transfer or Referral
- A brief summary of the reason for hospitalization. (This may be the hospital discharge summary if appropriate.)
- The principal diagnosis.
- A brief description of the hospital course of treatment.
- The patient’s condition at discharge, including cognitive status, functional status and social supports needed.
- The patient’s medication list. This list MUST be reconciled during the patient’s hospital stay to identify any changes made during the hospitalization. This should include over-the-counter and herbal medications.
- A list of drug allergies and interactions.
- Pending laboratory work or test results. This is extremely important for the community-based physician to know so that he can follow up on the results and not duplicate the tests as well!
- For patients being transferred to another facility, a copy of any advance directives should be included.
- For patients going home:
- A copy of the care instructions given to the patient or family caregiver while they were in the hospital.
- If applicable, a list of follow-up appointments with community-based providers.
- For patients with no established relationship with a practitioner, an appointment with a potential primary care provider, or health clinic, so that a relationship with a primary care provider can be established.
The Importance of Follow-Up Appointments
Post-discharge follow-up appointments have been demonstrated to be one important way to reduce hospital readmissions. A follow-up visit should take place shortly after a hospital discharge so that the patient has an opportunity to discuss any issues or concerns resulting from the hospitalization. It also gives the physician a chance to review and reinforce the post-hospital plan of care with the patient, for rehab to begin in a timely manner, and to clarify any concerns related to medication management or any other adjustments that might be needed to the pre-hospitalization plan of care.
You may find, as you look at your own process in assisting patients with follow-up appointments, that your process is not "hard-wired." Hard-wiring a process means that the process is such that no patients fall through the cracks. As case managers, we have not routinely performed this function as part of the discharge planning process. However, with all the changes in health care reimbursement, your hospital needs to be sure that you have a process that is standardized and consistent.
Standard 483.43(e): Reassessment
This standard states the following: "The hospital must reassess its discharge planning process on an on-going basis. The reassessment must include a review of discharge plans to ensure that they are responsive to discharge needs."
CMS considers your reassessment of your discharge planning program as part of the hospital-wide quality improvement program. Therefore, you should be demonstrating the performance of this reassessment on an annual basis. The reassessment should include the following:
- A review of discharge plans in closed medical records to determine whether they were responsive to the patient’s post-discharge needs.
- Did the discharge plan result in a readmission, and was it avoidable?
- You should track one interval of readmission 7, 15, 30 days or longer, on at least a quarterly basis.
- You should be reviewing a sample of 10% or 15 cases per quarter (whichever is larger) in order to determine whether there was an appropriate planning evaluation, discharge plan and implementation of the discharge plan.
You should also have a process to follow up on trends identified through analysis of readmissions. Examples might include readmission following post-operative infections, discharges from a particular unit, or discharges with the same diagnoses. You must analyze your hospital’s patterns and trends to better understand where you need to focus in reducing your own readmissions to the hospital.
Once you have identified these, or any other issues, you are then expected to re-review your policies and procedures to ensure that they address any issues that may be correctable.
The Conditions of Participation for Discharge Planning are the case manager’s guide as to how to correctly develop, implement and re-assess a hospital discharge planning program. Virtually any questions you may have as to how to conduct the discharge planning process can be found in the CoP. As case managers, we should never have to guess as to what the "right thing" is to do as it relates to discharge planning. Referring to the CoP any time a question comes up will always lead you in the right direction. n