Discharge Planning Advisor: Is it redundant to have DPs in addition to CMs?

Professionals talk semantics

Are the terms "discharge planning" and "case management" interchangeable, or are they distinct, and is there a place for both in today’s health care environment?

That’s the question raised by Sandra Lowery, RN, BSN, CRRN, CCM, president of the Francestown, NH-based case management consulting firm CCMI Associates, who adds, "I think it’s duplication to say there’s a discharge planner and a case manager within the same organization."

Working as a national consultant, Lowery says, she has observed that "in almost every hospital, if they haven’t implemented a case management department and dispensed with the discharge planning title, they’re planning to. Increasingly, the role of discharge planner is folded into case management."

Because the term "case management" or "care management" is used far more often, and almost always includes a discharge planning function, Lowery says, this leads to potential confusion on the part of those who are practicing the positions, as well as those who are receiving the services.

Jackie Birmingham, RN, BSN, MS, CMAC, a longtime case manager who now is vice president for regulatory compliance for Newton, MA-based Curaspan Inc., agrees that it can be confusing when people with different titles are performing the same or similar duties — a confusion that could be alleviated if there were more consistency across all hospitals.

She notes, however, that the function of discharge planning is not confusing. Discharge planning is a subset of case management, Birmingham adds, but specifically is "the work being done with the patient and family for the single purpose of setting up a safe discharge, so that the patient can transition to the next level of care without an adverse outcome."

The original definition of discharge planning, Lowery points out, "really sounds like case management from the point of admissions and discharge, with one or maybe two exceptions."

One of those exceptions, she says, is that while there is no requirement within the definition of discharge planning to consider the use of resources, such a directive is contained within the case management standard.

The other possible exception, Lowery says, is that the case management standard requires an evaluation of the outcome of the patient’s care plan. "I think there is some controversy over whether that last step is included in discharge planning. Some say yes; some say no."

Alison White, RN, CCM, CPHQ, director of regional case management for Dartmouth Hitchcock Alliance in Lebanon, NH, says that while she would prefer to see discharge planning become a subset of case management throughout the health care industry, she doesn’t believe it is a realistic goal.

"There are so many small, rural hospitals that don’t have an integrated model of case management," she adds. "Regardless of what we do, there will always be those with a distinct unit for discharge planning."

If people think in terms of how change is adopted into an organization, there are types ranging from the "early adopters" down to those who refuse to change at all, White notes. "For those organizations, discharge planning as a distinct unit may work.

"It depends on the patients they serve, or whether they have leadership that doesn’t want to change or is unaware of the benefits of case management," she adds. "Maybe the physicians don’t understand the concept, or it is a threat to them. If [the hospitals] don’t have a driver, they lose the opportunities to change," White explains.

In her experience working with institutions ranging in size from 12-16 beds up to 500 beds, White sees a number of hospitals that are not moving to the case management model, she says. "Or they think they’re in that model, but they’re not measuring outcomes or covering the continuum of care."

Because the term "discharge planning" is specified in the Medicare Conditions of Participation, which are part of the Social Security Act [Section 1861 (ee)], she notes, "we will never be able to do away with the term."

In fact, Birmingham points out, the federal rules regarding discharge planning were revised and published in the Federal Register Aug. 11, 2004, and went into effect in October 2004.

Some health care organizations are concerned about possible repercussions if they make changes in policies or definitions having to do with discharge planning, White says. "It’s an unfounded fear, but they’re worried that if they’re not clearly defining roles, they’ll lose payment."

Because some institutions, such as critical access hospitals, are paid on a daily basis for the care they provide, she says, "it may not be in their best interest to move more quickly along the continuum of care. There are a lot of drivers at the table.

"I would love to see discharge planning become an integrated part of case management," White points out, "but in reality I don’t feel it will [ever] be 100% across the United States."

That said, she adds, "I would challenge those who still have utilization review and discharge planning [functions] separately to reevaluate your model."

[For more information, contact:

Jackie Birmingham, RN, BSN, MS, CMAC, Vice President, Regulatory Compliance, Curaspan Inc., Newton, MA. Web site: jbirmingham@curaspan.com.

Sandra Lowery, RN, BSN, CRRN, CCM, President, CCMI Associates, Francestown, NH. Web site: ccmi@lowery.mv.com.

Alison White, RN, CCM, CPHQ, Director, Regional Case Management, Dartmouth Hitchcock Alliance, Lebanon, NH. Web site: Alison.B.White@Hitchcock.org.]