Discharge Planning in Case Management One of the more challenging aspects of a case manager s job is helping to ensure a patient successfully transfers from the hospital to the next level of care. Under a set of proposed revisions to Medicare s Conditions of Participation (CoP) announced in November 2015, this job may get even harder, more specific, and apply to more patients. The changes, among other things, will require hospitals, including critical access hospitals, to create discharge plans for more patients. Case managers will need a more direct plan to include patients and their caregivers in the discharge planning process, in particular taking into account their individual goals and preferences. This discharge planning process will also need to start sooner within 24 hours of admission. Under current regulations, hospitals must prepare formal discharge plans only for inpatients who need one. They also have to make arrangements for the plan s initial implementation. But CMS is now proposing that hospitals will need to expand the number of discharge plans they create to include: All inpatients Certain outpatients, including those { Receiving observation services { Having same-day surgery or other procedures with anesthesia or moderate sedation Select patients in the emergency room The rule also states that hospital staff members need to include patients and their caregivers in the discharge planning process, taking into account their individual goals and preferences. This discharge planning process will also need to start sooner within 24 hours of admission instead of the current 48-hour requirement. Hospitals will also need to communicate the plan including discharge instructions and summaries with the patient s primary July 2016 1
care physician within 48 hours so that he or she can provide follow-up care. Nor does discharge end when the patient walks out the door of the hospital; The expansion in the number of discharge plans the hospital will need to create represents a significant change for case management. providers at the facility will need to ensure that they follow up with the patient after he or she leaves by scheduling home visits or follow-up phone calls. The expansion in the number of discharge plans the hospital will need to create represents a significant change for case management. Most of the time, patients who are receiving observation services rarely receive a formal discharge plan because they re expected to leave the facility the following day. Under the proposed rule, however, staff members will need to create a formal discharge plan for every patient who undergoes an outpatient endoscopy or minor procedure such as cataract extraction or angiogram. Another challenging aspect of the proposed change would be the tightened timeline for performing patient assessments. The 24-hour deadline means case managers may no longer be able to delay starting a discharge plan for a patient who will remain hospitalized for a long period of time in favor of starting a discharge plan for a patient who is expected to leave the hospital sooner. Therefore, the new timeline will require hospitals to take a careful look at staffing. The foundation of discharge planning consists of three resource documents: The Social Security Act CoPs/Conditions for Coverage Interpretive Guidelines (IG) These three documents have overlapping purposes, with each adding more detail on how to perform discharge planning. For example, the Social Security Act for discharge planning explains the standards and is one page long. The CoP provide details regarding what discharge planners need to do to follow the standards as a condition of participating in Medicare and Medicaid and are about two pages in length. The IG section on discharge planning contains 2 July 2016
much more detail regarding how surveyors will interpret whether a hospital has met the CoP and can continue to care for Medicare and Medicaid patients is found in 42 CFR 482.43 Condition of Participation: Discharge Planning and is approximately 31 pages long. Why is this important? It is important to know that the discharge planning process is spelled out in great detail. Discharge planners can t rely on just one resource. Guidance on what each discharge planning standard means is in the CoP, and thus the CoP are a more useful tool. The IG has more detail than discharge planners need on a day-to-day basis. Discharge planning is a process within a profession rather than a profession in itself. Because a variety of professionals can perform discharge planning, the process must be structured consistently. Understanding how the process works is necessary to comply with the rules and regulations related to discharge planning. Most relevant legislation makes sense when put in context. Discharge planning is a process that provides a systematic basis for preparing a patient for discharge. It is a dynamic process because of the changing clinical status of the patient and changes in the healthcare system. It is also a process that can be used for consistent practice that meets regulatory and accrediting standards and is good for patients and the hospitals that serve their needs. July 2016 3
Resources 1. Case Management Monthly. (2016). 10 things you should know to ensure successful discharge planning. Retrieved from www.hcpro.com/cas-32 7227-2311/10-things-you-should-know-to-ensure-successful-dischargeplanning.html. 2. Case Management Monthly. (2016). Proposed rule focusing on discharge process could increase case management staffing needs. Retrieved from www.hcpro.com/cas-322889-2311/proposed-rule-focusing-on-dischargeprocess-could-increase-case-management-staffing-needs.html. 3. Case Management Monthly. (2016). Medicare s proposed discharge planning changes at a glance. Retrieved from www.hcpro.com/cas-32 6913-2311/Medicares-proposed-discharge-planning-changes-at-a-glance. html. 4. Briefings on Accreditation and Quality. (2016). Get ready for changes to CMS discharge planning requirements. Retrieved from www.hcpro.com/ QPS-324444-16/Get-ready-for-changes-to-CMS-discharge-planningrequirements.html. 5. Case Management Monthly. (2016). Discharge resource centers on the upswing. Retrieved from www.hcpro.com/cas-326912-2311/dischargeresource-centers-on-the-upswing.html. 6. Case Management Monthly. (2015). Prevent ED discharge failures. Retrieved from www.hcpro.com/cas-311446-2311/prevent-ed-dischargefailures.html. 7. HCPro. (2016). Discharge Planning: Realignment of Standards and Workflow - On-Demand Webcast. Retrieved from: http://hcmarketplace. com/discharge-planning-realignment-of-standards-and-workflow. 8. Medicare Compliance Watch. (2016). Q&A: Discharge planning for CAHs. Retrieved from http://www.medicarecompliancewatch.com/news-analysis/ qa-discharge-planning-cahs. 4 July 2016
References 9. MDS Central. (2015). Discharge planning proposed rule focuses on patient preferences. Retrieved from http://blogs.hcpro.com/mdscentral/2015/10/ discharge-planning-proposed-rule-focuses-on-patient-preferences. 10. Case Management Insider. (2015). New tool can help discharge planning process. Retrieved from www.hcpro.com/cas-313250-12341/new-toolcan-help-discharge-planning-process.html. 1. Federal Register. (2015). Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies. Retrieved from www.federalregister. gov/articles/2015/11/03/2015-27840/medicare-and-medicaid-programsrevisions-to-requirements-for-discharge-planning-for-hospitals. 2. CMS. (2015). Discharge Planning Proposed Rule Focuses on Patient Preferences. Retrieved from www.cms.gov/newsroom/mediarelease Database/Press-releases/2015-Press-releases-items/2015-10-29.html. 3. American Hospital Association. (2015). Revising the Requirements for Discharge Planning. Retrieved from www.aha.org/content/15/ psychcall15dec04-callslides.pdf. 4. AHA News Now. (2016). AHA comments on proposed discharge planning rule for hospitals, home health. Retrieved from http://news.aha.org/ article/160105-aha-comments-on-proposed-discharge-planning-rule-forhospitals-home-health. 5. American Hospital Association. (2016). Re: CMS 3317-P, Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies (Vol. 80, No. 212, Nov. 3, 2015). Retrieved from www.aha.org/advocacy-issues/ letter/2016/160104-cl-cms3317p.pdf. July 2016 5
6. CMS. (2014). Discharge planning booklet. Retrieved from www.cms.gov/ Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ Downloads/Discharge-Planning-Booklet-ICN908184.pdf. 7. State Operations Manual. (2015). Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Retrieved from www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/ som107ap_a_hospitals.pdf. 6 July 2016