Beef Up Your Processes for Discharge Planning

Hospital Access Management

June 24, 2014

As the Centers for Medicare & Medicaid Services (CMS) continues its emphasis on discharge planning, it's more important than ever to create a comprehensive discharge plan that provides everything patients need to manage in the next level of care, some experts say.

Beginning this year, surveyors will use a discharge planning worksheet to review how hospitals comply with the discharge planning portions of the Medicare Conditions of Participation (CoPs). As part of its Patient Safety Initiative, CMS has also developed worksheets to help surveyors assess compliance with the CoPs for performance improvement and infection control. The worksheets are designed to assist the surveyors and the hospital staff to identify when they are in compliance.

CMS has been pilot-testing the worksheets since 2011, according to Sue Dill Calloway, RN, MSN, JD, CPHRM, CCM, CCP, president of Patient Safety Education and Consulting in Dublin, OH. CMS tested the third revised surveyor worksheet in 2013 and came out with the final revised worksheet for discharge planning in March 2014. Surveyors will use the worksheet whenever a CMS survey is done. The updated infection control and quality improvement worksheets are expected to be finished this year.

"The worksheets are very important, and all hospitals that accept Medicare or Medicaid reimbursement should be intimately familiar with them," Dill Calloway says. "It doesn't matter who accredits hospitals; they have to be in compliance with the CMS standards. Hospitals have to comply with the Medicare Conditions of Participation or they could be fined or lose their ability to bill for Medicare and Medicaid."

The discharge planning survey worksheet gives hospitals a step-by-step guide to what CMS expects hospitals to be doing to comply with the CoPs, but it also is a blueprint for what hospitals should be doing anyway, says Laura Jacquin, RN, MBA, managing director for Huron Healthcare, a Chicago-based consulting firm. "The Conditions of Participation are patient-focused, patient-centric rules that spell out the right thing to do for patients. They are very much focused on providing an effective, comprehensive discharge plan with patient safety and preventing readmissions in mind," Jacquin says.

Hospitals must have discharge planning policies and procedures in writing, but it's not enough to just have them in place; you have to be able to follow them and show that you have done so, adds John Laursen, managing director for Huron Healthcare.

"The challenges we see as we work with clients is operationalizing the policies on a day-to-day basis," he says. "Case managers and the entire care team need to work together."

The surveyors will be reviewing hospitals' discharge policies and procedures to determine if they meet all the requirements of the CoPs and if they are in effect for all inpatients, not just Medicare patients, Jacquin says. They will look for evidence of discharge planning activities on every unit and will determine if the staff are following the discharge planning policies and procedures.

Dill Calloway suggests that hospitals put together a team to review all three worksheets and complete them as a self-assessment to make sure they are doing everything that CMS requires. The discharge planning worksheet reflects the changes made in the CMS standards on discharge planning that went into effect on July 19, 2013. "CMS completely rewrote all of the discharge standards in a 39-page memo that decreased the number of standards from 24 to 13," she adds.

CMS now publishes quarterly deficiency reports that show that many hospitals are receiving deficiencies in the discharge planning standards, Dill Calloway says. "In fact, in the January 2014 report, there were 364 deficiencies," she adds.

"The worksheet is a good communication tool to ensure that everybody in the organization is knowledgeable about the discharge planning standards. Sometimes the questions in the worksheet are not apparent from a reading of the CMS hospital interpretive guidelines. It is very important for every nurse, social worker, and discharge planner to be familiar with the discharge planning standards and incorporate them into their staff education and their hospital's policies and practices," she says.

The worksheet spells out what case managers should be assessing, says Michele Kala, RN, MS, a surveyor for the Chicago-based Healthcare Facilities Accreditation Program (HFAP), which has deeming authority from CMS.

The key issue in compliance is identifying patients who are at high risk for readmission and developing a discharge plan to make sure that wherever they go after discharge, they will be able to manage in a safe manner and stay healthy and out of the hospital, she says.

Those with limited resources might not have the staff to conduct a discharge planning evaluation on every patient. They should develop a mechanism to identify high-risk patients by diagnoses, severity of illness, and psychosocial needs, Kala says.

"If facilities don't have the resources to invest, it's acceptable to Medicare to create a discharge plan only for patients who are at risk," she says.

Very sick patients, discharged earlier

Patients who are admitted to the hospital tend to be very sick and are being discharged earlier than ever, says Jackie Birmingham, RN, BSN, MS, CMAC, vice president emerita of clinical leadership for Curaspan Health Group, a Newton, MA-based transition management software company.

"If the inpatient admission criteria set says the acute care hospital is the only place for patients to be, they should be assessed to determine where they should go next," Birmingham says.

The best practice for hospitals is to conduct a discharge planning evaluation on every patient, Dill Calloway adds. However, if you don't evaluate every patient, your policies and procedures must include a process to notify patients, family members, and attending physicians that they can request one, even if the patient doesn't meet high-risk criteria, she says.

The surveyors will look for a process to notify patients that they can request a discharge planning evaluation. Dill Calloway suggests that the information be included in the patient rights and responsibilities document and that the patients be asked to sign that document. The nurse also can inform the patient of his or her right to request an evaluation during the admission assessment and document it.

"Don't just hand the patients a sheet listing the patient rights," Dill Calloway says. "The best practice is for the registrar to give the patient the rights and responsibilities document at registration and go over the specific items."

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