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Overhaul Discharge Planning Processes to Comply With New CoPs1 |

Arlene Maxim

VP of Program Development, QIRT

Overhaul Discharge Planning Processes to Comply With New CoPs


CMS Proposed Rule

• Included discharge planning specifics

• However, when the CoPs were finalized, the expected detail of discharge planning was NOT included.

• There are significant discharge planning elements to the new CoPs that require attention.

• CMS has indicated that the IMPACT Act (proposed) has included extensive discharge planning that will take considerable implementation when finalized/implemented.


The IMPACT Act

• The IMPACT Act was signed on October 6, 2014 and requires the Secretary to publish regulations to modify CoPs and to develop interpretive guidance to require that HHAs take into account:

– Quality measures

– Resource use measures

– Other measures to assist post‐acute care providers, patients, and the families of patients with discharge planning

– Addressing the treatment preferences of patients and caregivers/support person(s) and the patients’ goals of care

2017 Copyright, DecisionHealth, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.


The IMPACT Act

As part of CMS’s efforts to update the current discharge planning/discharge summary requirements for several providers, CMS revised the previously proposed discharge or transfer summary requirements for HHAs in this proposed rule to incorporate the requirements of the IMPACT Act.

Proposal to add a new standard at § 484.58 for discharge planning.


The IMPACT Act

• The current regulations at § 484.48 require HHAs to prepare a discharge summary that includes the patient's medical and health status at discharge, include the discharge summary in the patient's clinical record, and send the discharge summary to the attending physician upon request.

• CMS will update the discharge summary requirements by requiring that HHAs better prepare patients and their caregiver/support person(s) (or both) to be active participants in self‐care and by implementing requirements that would improve patient transitions from one care environment to another, while maintaining continuity in the patient's plan of care.


The IMPACT Act

• A new Condition at § 484.58, will require that HHAs develop and implement an effective discharge planning process that focuses on:

– Preparing patients and caregivers/support person(s) to be active partners in post‐discharge care.

– Effective transition of the patient from HHA to post‐HHA care.

– Reduction of factors leading to preventable readmissions.



CMS Proposal for New CoP‐§484.58(a)

1. Discharge Planning Process (Proposed §484.58(a))• We propose to establish a new

standard, Discharge Planning Process, to require that the HHA's discharge planning process ensure that the discharge goals, preferences, and needs of each patient are identified and result in the development of a discharge plan for each patient.

• In addition, we propose to require that the HHA discharge planning process require the regular re‐evaluation of patients to identify changes that require modification of the discharge plan, in accordance with the provisions for updating the patient assessment at current § 484.55.

• The discharge plan must be updated, as needed, to reflect these changes.



• CMS reminds HHAs that they must continue to abide by federal civil rights laws, including Title VI of the Civil Rights Act of 1964, the Americans with Disabilities Act, and section 504 of the Rehabilitation Act of 1973, when developing a discharge planning process.

• To this end, HHAs should take reasonable steps to provide individuals with limited English proficiency or other communication barriers, or physical, mental, cognitive, or intellectual disabilities meaningful access to the discharge planning process, as required under Title VI of the Civil Rights Act, as implemented under 45 CFR 80.3(b)(2).



• Discharge planning would be of little value to patients who cannot understand or appropriately follow the discharge plans discussed in this rule.

• Without appropriate language assistance or auxiliary aids and services, discharge planners would not be able to fully involve the patient and caregiver/support person in the development of the discharge plan.

• Furthermore, the discharge planner would not be fully aware of the patient's goals for discharge.




• We propose to require that the physician responsible for the home health plan of care be involved in the ongoing process of establishing the discharge plan.

• We believe that physicians have an important role in the discharge planning process and we would expect that the HHA would be in communication with the physician during the discharge planning process.



• We also propose to require that the HHA consider the availability of caregivers/support persons for each patient, and the patient's or caregiver's capacity and capability to perform required care, as part of the identification of discharge needs.

• Furthermore, in order to incorporate patients and their families in the discharge planning process, we propose to require that the discharge plan address the patient's goals of care and treatment preferences.



• For those patients that are transferred to another HHA or who are discharged to a SNF, IRF, or LTCH, we propose to require that the HHA assist patients and their caregivers in selecting a PAC provider by using and sharing data that includes, but is not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource‐use measures.

• We would expect that the HHA would be available to discuss and answer patient's and their caregiver's questions about their post‐discharge options and needs.

• Furthermore, the HHA must ensure that the PAC data on quality measures and data on resource use measures are relevant and applicable to the patient's goals of care and treatment preferences.




• As required by the IMPACT Act, HHAs must take into account data on quality measures and resource use measures during the discharge planning process.

• In order to increase patient involvement in the discharge planning process and to incorporate patient preferences, we propose that HHAs provide data on quality measures and resource use measures to the patient and caregiver that are relevant to the patient's goals of care and treatment preferences.

• For example, the HHA could provide the aforementioned quality data on other PAC providers that are within the patient's desired geographic area. HHAs should then assist patients as they choose a high quality PAC provider by discussing and answering patient's and their caregiver's questions about their post‐discharge options and needs.



• We would expect that HHAs would not make decisions on PAC services on behalf of patients and their families and caregivers and instead focus on person‐centered care to increase patient participation in post‐discharge care decision making.

• Person‐centered care focuses on the patient as the focus of control, supported in making their own choices and having control over their daily lives.



• We propose to require that the evaluation of the patient's discharge needs and discharge plan be documented and completed on a timely basis, based on the patient's goals, preferences, and needs, so that appropriate arrangements are made prior to discharge or transfer.

• This requirement would prevent the patient's discharge or transfer from being unduly delayed.

• In response to this requirement, we would expect that HHAs would establish more specific timeframes for completing the evaluation and discharge plans based on their patient's needs and taking into consideration the patient's acuity level and time spent in home health care.




• We propose to require that the evaluation be included in the clinical record. We propose that the results of the evaluation be discussed with the patient or patient's representative.

• Furthermore, all relevant patient information available to or generated by the HHA itself must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the patient's discharge or transfer.



Discharge or Transfer Summary Content (Proposed § 484.58(b))• We propose at § 484.58(b) to establish a new standard, Discharge or Transfer

Summary Content, to require that the HHA send necessary medical information to the receiving facility or health care practitioner.

• The information must include, at the minimum, the following:– Demographic information, including but not limited to name, sex, date of birth, race, ethnicity,

and preferred language– Contact information for the physician responsible for the home health plan of care– Advance directive, if applicable– Course of illness/treatment– Procedures– Diagnoses– Consultation results– Functional status assessment– Psychosocial assessment, including cognitive status– Social supports– Behavioral health issues– Reconciliation of all discharge medications (both prescribed and over‐the‐counter)



• The information must include, at the minimum, the following (continued):– All known allergies, including medication allergies– Immunizations– Smoking status– Vital signs– Unique device identifier(s) for a patient's implantable device(s), if any– Recommendations, instructions, or precautions for ongoing care, as

appropriate– Patient's goals and treatment preferences– The patient's current plan of care, including goals, instructions, and

the latest physician orders– Any other information necessary to ensure a safe and effective

transition of care that supports the post‐discharge goals for the patient




• As part of the medication reconciliation process, we encourage practitioners to consult with their state's Prescription Drug Monitoring Program (PDMP).

The Prescription Drug Monitoring Program (PDMP) collects information on all filled prescriptions for controlled substances. This information helps health care providers safely prescribe controlled substances and helps patients get the treatment they need.


Prescription Drug Monitoring Program (PDMP)

https://www.cdc.gov/drugoverdose/pdmp/


Prescription Drug Monitoring Program (PDMP)

How can I register and use the PDMP in my state?

• Processes for registering and using PDMPs vary from state to state.

• For information on your state’s requirements, check the National Alliance for Model State Drug Laws online: www.namsdl.org/prescription‐monitoring‐programs.cfm




• We propose to include these elements in the discharge plan so that there is a clear and comprehensive summary for effective and efficient follow‐up care planning and implementation as the patient transitions from HHA services to another appropriate health care setting.

• We note that many of the aforementioned proposed medical information elements required to be sent to the receiving facility or health care practitioner may not be applicable to the patient.

• Therefore, we would expect HHAs to include this information with N/A or other appropriate notation next to each data element that does not apply to the patient.


Frequency of Discharge/Transfer Mentioned in the 2017 CoPs

• 484.50‐Patient RightsDischarge and Transfer• CMS requires acceptable physical or electronic documents outlining acceptable reasons for discharge or transfer.

• They indirectly include discharge for staff safety reasons, but for cause, standards may apply.

• They did not include inadequate clinical resources as a ‘for cause ‘ basis for discharge.

• Agencies need to review state licensing law requirements on discharge an apply standards that protect patients.

• 484.55 Comprehensive Assessment

• 484.60 Care Planning

• 484.110 Clinical Records


§484.50 Condition of Participation:Patient Rights

The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights.

Standards(a) Notice of rights

(b) Exercise rights

(c) Rights of the patient

(d) Transfer and discharge

(e) Investigation of complaints

(f) Accessibility



§484.50 Patient Rights

Standard –Transfer and discharge NewThe patient and representative (if any), have a right to be informed of the HHA’s policies for admission, transfer, and discharge.

HHA may only transfer or discharge the patient from the HHA if:1) Acuity requires another level of care—HHA must arrange for safe and

appropriate transfer2) No payment3) Physician and HHA agree that goals met4) Patient refuses care or elects transfer/discharge5) Cause – disruptive, abusive, uncooperative behavior;

i. Advise patient, physician etc. of the plan to d/trii. Efforts to resolve problems prior to d/triii. Provide patient with contact information for other agencies/providersiv. Document efforts made to resolve issues

6) Death7) HHA ceases to operate


§484.50 Patient Rights

• The notice of rights is more extensive because of things such as the requirement to list consumer protection agencies and language services and their contact information.

• Notice of Rights ‐ written and verbal notice in preferred language. CMS expects HHAs to utilize technology, such as telephonic interpreting services and any other available resources for oral communication in the patient’s primary or preferred language prior to the completion of the second skilled visit.– Agency must provide the patient and the patient’s legal representative the

following information at the time of the initial evaluation:• Written notice of the patient's rights/responsibilities under the rule and written

documentation regarding the HHAs transfer and discharge policies• Contact information for the agency administrator, including name, business

address, business phone number for complaints.• OASIS Privacy Notice


§484.55 Comprehensive Assessment

The patient’s strengths, goals, and care preferences, including information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; Pg. 4531

“Traditionally the home health plan of care has been developed with a focus on patient deficits that require treatment …. This model of care places patients in a passive recipient role that does not optimize the achievement of positive patient outcomes. First, this model does not take into account those patient‐strengths that can be harnessed by the HHA staff and plan of care to facilitate patient well‐being. ……. Each patient has their own set of care preferences, and we would require HHAs to both identify and respect these care preferences to the greatest degree possible. Our goal is to assure that HHAs plan for and provide care that is both patient‐directed and in accordance with the physician ordered plan of care.”

a) The patient’s continuing need for home care

b) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs

c) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy



§484.55 Comprehensive Assessment

§484.55(d) Update of the comprehensive assessment comprehensive assessment.

The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than:

1) The last 5 days of every 60 days beginning with the start‐of‐care date, unless there is a:

i. Beneficiary elected transfer

ii. Significant change in condition; or

iii. Discharge and return to the same HHA during the 60‐day episode.

2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician‐ordered resumption date

3) At discharge.


§484.60 Care Planning, Coordination of Services and the Quality of Care Delivered

Services must be furnished in accordance with accepted standards of practice.

Standards:

a) Plan of care

b) Conformance with physician orders

c) Review and revision of the plan of care

d) Coordination of care

e) Discharge or transfer summary


§484.60 Care Planning, Coordination of Services and the Quality of Care Delivered

• Coordination of Care

– Integrate services.

– Coordinate between disciplines and communicate with physician.

– Ongoing training to assure timely discharge.

• Discharge and Transfer Summary



484.110 Clinical Record

a) Contents of the clinical record. The record must include:

1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician orders.

2) All interventions, including medication administration, treatments, and services, and responses to those interventions.

3) Goals in the patient’s plans of care and the patient’s progress toward achieving them.

4) Contact information for the patient and the patient’s representative (if any).


484.110 Clinical Record (cont.)

5) Contact information for the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA.

i. A completed discharge summary that is sent to the primary care practitioner or other health care who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or

i. A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or

i. A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer.


Type of Rights Document Receiving Entity Time Frame for Delivery

Written notice of rights and responsibilities/transfer and discharge policies in language understood and accessible to individuals with disabilities

Patient and legal representative with signature

Prior to care being initiated

Verbal rights and responsibilities

Patient and legal representative

No later than the completion of the second visit from a skilled professional

Written notice of rights and responsibilities/transfer and discharge policies in language understood and accessible to individuals with disabilities

Patient selected representative 4 business days



Why All the Attention On Transfers/Discharges?


National Quality Forum (NQF) Safe Practice Discharge Measures

• The NQF Safe Practice is essential in delivering safe and effective discharges‐from home or hospital.

• The NQF identifies a key set of intermediate process variables leading to re‐hospitalizations.


Measures Endorsed by National Quality Forum (NQF)

1. Outcome measures include a reduction in direct harm associated with adverse events and medical errors to include:– Death.

– Disability (permanent or temporary).

– Adverse drug events.

– Preventable harm requiring further treatment.

– Missed diagnoses.

– Delayed treatment.

– Inaccessible prior test information and medical records.




2. Process measures include:– Percentage of discharge summaries

received by accepting practitioners.

– Number of patients who have and attend post‐hospital follow‐up appointments.

– Timeliness of receipt and discussion of post‐hospital follow‐up tests with the accepting provider.



3. Home Management Plan of Care Document given to the patient/caregiver.– Documentation exists that the home

management plan of care, as a separate document, specific to the patient, was given to the patient/caregiver prior to or upon discharge.



4. Structure measures:– Verification of the existence of a

systematized discharge performance improvement program and explicit organizational policies and procedures addressing:

• Communication of discharge information.

• Verification of educational programs.

• The existence of formal reporting structures for accountability across governance, administrative leadership, and caregivers.




5. Patient‐centered measures:– Include surveys of patient satisfaction

following discharge at the time of and after discharge (HHCAHPS surveys).


Re‐working Your Discharge Policies


Why Re‐work Your Discharge Process?

• Need timely Transfer and Discharge Summaries– A delay in summaries means the receiving entity (hospital/physician

office) is not immediately aware of which conditions need immediate attention..

• Unknown Test Results– Test results (if any) need to be known to referring entity to avoid

duplication as well as provide additional information re: patient condition.

• Lack of Follow‐up– Patients do not always know what is needed following discharge. They

may not know how to make necessary appointments, etc. Studies indicate more than 1/3 of patients following hospitalization need more care. Those being discharged from homecare often require follow‐up appointments/office visits to prevent re‐hospitalizations.

• Medication Reconciliation and Adverse Events– Confusion regarding medications is one of the primary reasons for re‐

hospitalizations.



Stay in the RED

Hospitals and emergency rooms nationwide are using a standard of practice called “RED” (Re‐engineered Discharge)

RED Impact on Hospitals

– Improved Clinical Outcomes• Decreased 30 day re‐admission by 25%• Decreased ER use from 24% to 16%• Improve primary physician follow‐up

– Meets Safety Standards and Improves Documentation• Documents discharge preparation• Documents understanding of the discharge plan• Reduced cost by $412/patient• Improved market share as a preferred provider

– Improves Patient Centeredness and Hospital’s Community Image• Branded hospital as a high‐quality facility• Improved patient satisfaction


7 Step Plan to Re‐Work Discharge Planning In Your Agency

Step 1: Write a clear policy. In the policy indicate WHY discharge planning is a priority in your agency and what you hope to achieve. For instance:

– Improved patient satisfaction– Decreased re‐admission rates

Step 2: Identify implementation team.Prepare a GAP analysis re:

– Patient safety issues– Case management– Patient/family education– Interpretation services


7 Step Plan to Re‐Work Discharge Planning In Your Agency (cont.)

Step 3: Analyze hospital re‐admission rates and determine goals.

– What is current rate of readmissions?

– What is rate per diagnosis?

– What is rate by physician/hospital referral?

– Determine what data you will need to determine success.




Step 4: Identify patients at high risk for admissions.– Age– Length of stay during most recent hospitalization– Comorbidities– Number of readmissions in 6 months– Overall health and function– Illness severity– Poor social connections– Low literacy– Depression– Substance abuse– Poor follow‐up with physicians– Male gender



Step 5: Create a process map.Allows you to visualize the agency discharge process. Benefits include, but are not limited to:

– Identify tasks that need to be accomplished before the individual patient is discharged

– Indicates potential problems with impending discharge– Stimulates new thinking re: team members responsibilities

toward safe discharge

Discharge Process Map should:List all team members involved in discharge.Indicate how discharges work on holidays and weekends.



Step 6: Assign discharge responsibilities.

– Hire discharge planner

– Hire pharmacist or pharmacy tech

Step 7: Generate an after homecare plan.

– Develop specific plan for each individual patient• Medication list reconciled

• List of appointments with dates and times

• List of transportation possibilities

• Instructions on re‐starting home health if needed



Summary

• Carefully review 2017 Conditions referencing DISCHARGE/TRANSFER

• Review proposed IMPACT rule

• Train staff on new requirements

• Begin testing discharge systems put into place

• Begin using the Re‐Work Discharge Planning Tool


Disclaimer:

• QIRT (Quality in Real Time)© presentations are intended for educational purposes only and do not replace independent professional judgment. Statements of fact and opinions expressed are those of the participants individually and, unless expressly stated and identified to the contrary, are not the opinion or position of the bodies that govern and regulate healthcare. Attendees should note that sessions are audio‐recorded and may be published in various media, including print, audio and video formats without further notice.


Thank You

Questions?


Discharge Criteria ______________________ POLICY

Patients are discharged by Agency based on specifically defined criteria. ______________________ PURPOSE

To establish guidelines for discharge of patients from the Agency. ______________________ REFERENCE

Medicare §484.50 Condition of Participation: Patient Rights ______________________ RELATED DOCUMENTS

“Discharge Instructions,” “Discharge Summary” forms ______________________ PROCEDURE

1. Patient will be discharged from services as follows: Patient expires. Patient moves out of service area. Patient requests to be discharged (will be verified with patient’s physician). Patient’s therapy or treatment has been completed and services are no longer needed,

e.g., patient goals are met. Services can no longer be provided safely and/or effectively in the patient’s place of

residence (patient’s physician will be consulted for alternative follow up care and/or referral).

Patient refuses to follow physicians prescribed plan of care/treatment (physician will be notified).

Physician orders discharge of patient from service. Patient is no longer homebound.

2. The patient is informed of discharge plan in a timely manner and acknowledges

understanding reason. 3. Physician and other care providers will be informed and knowledgeable of discharge. 4. Discharge planning begins at time of admission and will be reflected in the

documentation.


5. Staff will be knowledgeable about discharge procedures including instructions and follow-up responsibilities.

6. The patient’s continuing care needs, if any, are assessed at discharge. 7. Patients will receive verbal or written discharge instructions. 8. A complete list of reconciled medications will be provided to each patient on discharge.

The list will be explained to patient/family and interaction documented. Patients and families will be reminded to discard all old medication lists and to update health records with physicians and retail pharmacies.
