CMS raised the bar for discharge planning in its May 17 compliance guidance under the Medicare conditions of participation (CoP). In addition to pinning its hopes on discharge planning to foil readmissions, CMS sees it as part of the “shared responsibility” of health care professionals, patients and facilities throughout the continuum of care, according to revised interpretive guidelines in the state operations manual.
Interpretive guidelines are used by state surveyors to evaluate hospital compliance with Medicare conditions of participation. If hospitals drop the ball in any area, they are cited for deficiencies and could lose their Medicare certification. The Department of Justice has pursued False Claims Act lawsuits based on violations of the conditions of participation, but so far it has been rebuffed by the courts for the most part.
The conditions of participation require hospitals to have written discharge plans for all inpatients, and the interpretive guidelines put meat on the bones of this mandate. Surveyors determine how good hospitals are at assessing and reassessing post-hospital needs, arranging post-acute services, and teaching self-care. New best practices appear in the 39-page document, but hospitals can take them or leave them. For example, CMS suggests that hospitals do “abbreviated post-hospital planning” for outpatients and observation patients in light of the growing complexity of outpatient services.
“There is a lot more detail,” says Steven McGaffigan, director of case management at Tampa General Hospital. “Some people might see this as more intrusive, but hospitals have to stop discharging to the door.” Everyone benefits from effective discharge planning, which improves patient satisfaction, reduces readmissions and unburdens emergency rooms if post-hospital services and patient education keep hospitals out of the revolving-door business, he says.
CMS Raises Discharge Planning Bar
Although CMS emphasizes the goal of reducing readmissions, there is more to the interpretive guidelines. “Some of what is in here is speaking to ‘post-hospital syndrome,’” McGaffigan says. The term, coined by Harlan Krumholz, M.D., in the Jan. 10, 2013, New England Journal of Medicine, refers to “an acquired, transient period of vulnerability.” Patients may not anticipate how much they will be affected by the hospitalization, McGaffigan says. “You are not yourself and you have to remember the new medications and the changes to your diet and wound care and whether you can shower.” CMS also tries to capture progressive ideas about discharge planning by recognizing newer terms, such as “community care transitions.” The language “pushes us to think more broadly about discharging a patient. The hospital is not the only point in the patient’s interaction with the health care delivery system,” McGaffigan says.
Hospitals should use the interpretive guidelines to audit their own discharge planning process, says Steven Meyerson, M.D., vice president of the regulations and education group at Accretive Physician Advisory Services, who spoke on the topic at a RACmonitor.com mini-webinar on June 3. “They are very specific,” he says. “There are a lot of documentation requirements,” such as updating the discharge plan if the patient’s condition changes and reviewing it periodically. He notes the interpretive guidelines take effect immediately.
The reduction of readmissions is a centerpiece of the interpretive guidelines. Readmissions are unhealthy for patients and pricey for hospitals, with the Medicare readmission reduction program now cutting base DRG payments for “excess” readmissions within 30 days for pneumonia, congestive heart failure and acute myocardial infarction (RMC 10/22/12, p. 1). In the fiscal year 2014 inpatient prospective payment system regulation, CMS proposes to expand the program to readmissions for acute exacerbation of chronic obstructive pulmonary disease and elective total hip arthroplasty and total knee arthroplasty. Certain readmission measures are also linked to Medicare payment through value-based purchasing and the inpatient quality reporting program.
“While hospitals are not solely responsible for the success of their patients’ post-hospital care transitions, under the discharge planning CoP hospitals are expected to employ a discharge planning process that improves the quality of care for patients and reduces the chances of readmission,” CMS says.
The interpretive guidelines describe the elements of the discharge planning CoP and spell out the new requirements. Here are excerpts:
(1) Screening patients for the risk of bad outcomes in the event there is no discharge planning.Hospitals must “voluntarily” develop discharge plans for all patients or have clear policies on who gets one and why. They must decide early after admission whether patients need discharge planning and get to work on it promptly. There won’t be sanctions as long as discharge planning is underway up to 48 hours before the patient’s departure and there aren’t delays due to the hospital’s failure to finish the evaluation. Even patients who stay fewer than 48 hours are entitled to an evaluation. In a blue box, CMS advises hospitals to assume all patients need some kind of discharge planning given the risk of “adverse health consequences” after discharge.
(2) Evaluating post-discharge needs for inpatients who are at risk or if this is requested by the patient, patient’s representative or physician. CMS added two major items to the overall requirement: The discharge planning must include an evaluation of (a) the patient’s potential need for post-hospital services and their availability, and (b) the “patient’s capacity for self-care” or for care in the location they came from. If family members or caregivers can’t handle all of the patients’ needs, the hospital should determine whether services exist to help them stay home (e.g., home health, respiratory therapy).
(3) Designing a discharge plan if necessary. Only a registered nurse, social worker or other appropriate staff can do it. The plan should match the needs identified in the evaluation and patients may participate.
(4) Initiating the discharge plan before patients leave. Discharge planning should be collaborative, CMS says, involving patients and their caregivers. Outcomes are improved when patients who are discharged home are taught about their disease processes, medications, treatments, expected symptoms and when and how to get help, and when they are given supplies, such as bandages, and user-friendly discharge instructions, preferably in checklist form. In a blue box, CMS suggests that hospitals consider filling patients’ prescriptions before discharge, scheduling follow-up appointments, and using remote monitoring technology, such as pulse oximetry and daily weigh-ins for congestive heart failure.
The interpretive guidelines won’t require many changes at Tampa General Hospital, McGaffigan says. “We attach to patients at admission and follow them through the inpatient stay,” he says. Case managers determine the appropriate setting — inpatient vs. outpatient/observation — and evaluate their post-discharge needs, McGaffigan says. Inappropriate admissions obviously are risky in terms of Medicare claim denials but overuse of observation can stick beneficiaries with higher out-of-pocket expenses.
Tampa General assigns patients to one of three categories — A, B or C — according to their discharge complexity (see box, p. 6). “A” is for simpler discharge planning needs, “B” is moderately complex and “C” is complex. Case managers, nurses and/or social workers also quickly determine whether the patient is a readmission from the previous 30 days. If that’s the case, they investigate the reason the patient is back and discuss what could be done differently to encourage a better outcome (e.g., caregiver support, transportation to doctor’s appointments, home health care). “Then we have huddles on the nursing unit on a daily basis where we re-address whether the patients’ discharge needs have changed,” he says.
McGaffigan has also learned that patients don’t want discharge sprung on them. “There is too much information they have to absorb,” he says. And they may need help when they get home to prevent readmissions and promote patient satisfaction. For example, hospitals are moving in the direction of ensuring patients have follow-up visits with their physicians, discussing how they will get medical equipment and sending someone over to ensure they understand their new medication regimen and toss out old drugs. “Patients want us to do that,” McGaffigan says. “They don’t want to get home and have a lot of questions and not feel ready and feel panicked.” Patient satisfaction is a big part of CMS’s value-based purchasing program through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.
Although CMS does not mandate the steps in the blue boxes, he sees it as a segue to a future where health systems are paid a lump sum to manage covered lives. “It’s about thinking more of what will transpire in the days after patients leave the hospital,” he says.
Improving the Patient Discharge Planning Process
The revised interpretive guidelines for Medicare conditions of participation on discharge planning may not be as challenging for Tampa General Hospital because it has a tiered system to evaluate discharge-planning needs within 24 hours of the patient’s admission, says Steven McGaffigan, director of case management. The hospital assigns patients to one of three categories — A, B or C — depending on the anticipated complexity of their post-discharge experience, and then reassesses during the stay. Contact McGaffigan at
smcgaffigan@tgh.com.
