Be ready for the discharge planning surveyor worksheets

Dust off those CoPs and educate your staff

As the Centers for Medicare & Medicaid Services (CMS) moves to reimbursing hospitals for quality, the agency is paying more attention to discharge planning and is pilot testing worksheets to review how hospitals comply with the Medicare Conditions of Participation as they relate to discharge planning.

In addition to the discharge planning worksheet, CMS is developing patient safety worksheets that surveyors will use to help assess compliance with hospital Conditions of Participation for quality assessment and performance improvement and infection control. CMS says the worksheets are designed to be effective tools for surveyors to use in assessing compliance and to serve as risk-management assessment tools for hospitals.

The fact that CMS ranks discharge planning with quality assessment and performance improvement and infection control and includes it in a patient safety initiative is evidence of the emphasis that the agency is putting on discharge planning and preventing readmissions, says Jackie Birmingham, RN, BSN, MS, CMAC, a nurse educator based in Suffield, CT.

“CMS is making it clear that discharge planning is a patient safety issue and that it expects hospitals to be concerned with what happens to patients across the continuum of care and not just when they are in the hospital,” Birmingham says.

CMS did not have worksheets for surveyors until it announced the first draft of the worksheets in October 2011, says Sue Dill Calloway, RN, MSN, JD, CPHRM, CCM, CCP, president of Patient Safety Education and Consulting in Dublin, OH. CMS issued its third revision of the worksheets that surveyors use for hospital surveys on Nov. 9, 2012, after the worksheets were pilot-tested twice. In the third pilot, surveyors will select between 1 and 9 hospitals in each state, depending on the size, and will use all three worksheets. Hospitals with higher than average readmissions for all causes are likely to be targeted for a survey, Dill Calloway says.

Hospitals that participate in Medicare or Medicaid must meet the Conditions of Participation for all patients in their facility, regardless of payer source. Hospitals with deemed status can still be subject to a complaint survey or a validation survey on the Conditions of Participation, Dill Calloway says.

“Information only”

In addition to questions that indicate compliance with the current Conditions of Participation, the worksheets include “information only” questions that CMS will use to determine what will be added to the Conditions of Participation in the future, Birmingham says. “The worksheets list not only what CMS now expects hospitals to do to comply but also what they may be considering including in the Conditions of Participation in the future,” Birmingham says. Even if CMS does not change the Conditions of Participation, it will change what it looks for in compliance with the Conditions of Participation during the survey process, Birmingham adds. “The items in this pre-survey worksheet will be added to the Interpretive Guidelines used by surveyors to determine compliance with the Conditions of Participation,” she says.

Case managers should pay careful attention to the “information only” components of the survey worksheets, because they provide an opportunity to learn what Medicare thinks is important and to prepare for the time that these components may be added to the Interpretive Guidelines for compliance with the Conditions of Participation, Birmingham says. “It’s not only a way of determining what may be required for compliance in the future, but it also offers an opportunity to guide discharge planners in developing best practices in patient care and transitions,” she says.

The discharge planning survey worksheets are all part of CMS’ movement to encourage hospitals to prevent unnecessary readmissions, says Elizabeth Hogue, Esq., a Washington, DC, attorney specializing in healthcare issues.

“There is increasing agreement in the industry that care transitions from one level of another are a key point at which interventions are needed to prevent rehospitalizations,” she says.

Beginning with discharges on Oct. 1, 2012, CMS began penalizing hospitals for excess readmissions. The new Value-Based Purchasing initiative will include Medicare spending-per-beneficiary beginning in fiscal 2015.

Readmissions and Medicare spending-per-beneficiary are now being reported on Hospital Compare, Birmingham points out. In addition, three new questions on transitions of care have been added to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), she says.

Discharge planning is important in today’s environment, especially in light of healthcare reform laws, Dill Calloway points out. “Reimbursement is driving hospitals’ behavior. The bottom line is that two out of three hospitals lost money under the readmission reduction program and value-based purchasing,” she says.

Dill Calloway recommends that hospitals put together a team to review the worksheets and complete the forms in advance as a self-assessment. Then, if there is a survey, the worksheet can be shown to the survey as part of the survey readiness process.

Hogue adds: “The Conditions of Participation may have gotten short shrift in the past, but that no longer can be the case. Case managers may not have reviewed them recently. Now is the time to take a good hard look at what they require.” She advises case management directors to educate their staff about the Conditions of Participation and the contents of the worksheets.

Policies and procedures

Review the pilot surveyor worksheet and take note of the areas that CMS is concerned about, determine where your hospital needs improvement, then tailor process improvement projects to ensure that you are in compliance with the Conditions of Participation now and will be in the future, Hogue says.

Hospitals need to have policies and procedures in place on admission screening, assessing patients for care coordination needs, and giving patients choices of appropriate and available discharge destinations, Birmingham says.

The surveyors are going to make sure that the discharge policies and procedures are in effect for every inpatient and that staff follow the policies and procedures, Dill Calloway says. In addition, the worksheets determine if there is a discharge planning process for outpatients receiving observation services, emergency department patients, and same-day surgery patients.

Surveyors can interview the patients as well as physicians to determine whether they are aware that they can request a discharge planning evaluation, Dill Calloway says.

If physicians are not aware that they can request a discharge planning evaluation, the surveyors will ask the hospital about how they inform the doctors, she says.

The underlying Conditions of Participation on which the worksheet is based did not change, but some of the questions may not be apparent from reading the Conditions of Participation, Dill Calloway says.

For example, the patient is discharged on Monday with heart failure. The hospital makes the follow-up appointment with the primary care physician for Thursday at 10 a.m. The worksheet states that the necessary medical information, which can be in the discharge summary, must be in the hands of the provider prior to that appointment, Dill Calloway says. If a follow-up appointment is not made, the medical record information must be sent to providers within seven days. This is not a requirement stated in the Conditions of Participation, she says.