October 29, 2015: CMS Releases a Discharge Planning Proposed Rule
Published on
Tuesday, November 3, 2015
“Hospital discharge planning is a process that involves determining the appropriate post-hospital discharge destination for a patient; identifying what the patient requires for a smooth and safe transition from the hospital to his/her discharge destination; and beginning the process of meeting the patient’s identified post-discharge needs.”- Pub. 100-07, State Operations Manual, Appendix A- Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (Rev. 149, 10-09-15)
Whether true or not it seems the longer I work in health care the more it becomes apparent that when CMS makes “suggestions for process changes” sooner or later suggestions become requirements. Flash back to May 17, 2013 when CMS released updates to Appendix A of the State Operations Manual providing revised interpretive guidelines for the Discharge Planning Conditions of Participation (CoPs) at 42 CFR 482.43. Notably, this revision included “blue boxes” that CMS indicated displayed “successful practices currently found throughout the industry in the area of care transitions.”
Fast forward to October 29,2015 when CMS announced proposed revisions to the discharge planning requirements that hospitals, including long-term care hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Critical Access Hospitals (CAHs), and Home Health (HH) agencies must meet in order to participate in the Medicare and Medicaid program. Several of the “blue boxes” are now being proposed as requirements.
While there are other proposals being made, this article focuses on the proposed changes specific to Discharge Planning in the Acute Care Hospital setting.
PROPOSED RULE BACKGROUND
Legislative History
The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires the standardization of Post-Acute Care (PAC) assessment data that can be evaluated and compared across PAC provider settings, and used by hospitals, CAHs, and PAC providers, to facilitate coordinated care and improved Medicare beneficiary outcomes.
CMS notes that they are currently developing additional public guidance and that many of the PAC provisions are being addressed in separate rulemakings. More information can be found on the CMS website at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014-and-Cross-Setting-Measures.html .
This Proposal would implement the discharge planning requirements mandated in section 1899B(i) of the IMPACT Act by modifying the discharge planning or discharge summary Conditions of Participation (CoPs) for hospitals, CAHs, IRFs, LTCHs, and HHAs. The IMPACT Act identifies LTCHs and IRFs as PAC providers, but the hospital CoPs also apply to LTCHs and IRFs since these facilities, along with short-term acute care hospital, are classifications of hospitals. All classifications of hospitals are subject to the same hospital CoPs. Therefore, these PAC providers (including freestanding LTCHs and IRFs) are also subject to the proposed revisions to the hospital CoPs.
PROVISIONS OF THE PROPOSED REGULATIONS
Hospital Discharge Planning
The Medicare CoPs and Conditions for Coverage (CfCs) set forth the federal health and safety standards that providers and suppliers must meet to participate in the Medicare and Medicaid programs. The purposes of these conditions are to protect patient health and safety and to ensure that quality care is furnished to all patients in Medicare and Medicaid-participating facilities. In accordance with section 1864 of the Act, CMS uses state surveyors to determine whether a provider or supplier subject to certification qualifies for an agreement to participate in Medicare. However, under section 1865 of the Act, providers and suppliers subject to certification may instead elect to be accredited by private accrediting organizations whose Medicare accreditation programs have been approved by CMS as having standards and survey procedures that meet or exceed all applicable Medicare requirements.
The current hospital discharge planning requirements at §482.43, “Discharge planning,” were originally published on December 13, 1994 (59 FR 64141), and were last updated on August 11, 2004 (69 FR 49268). Under the current discharge planning requirements, hospitals must have in effect a discharge planning process that applies to all inpatients. The hospital must also have policies and procedures specified in writing.
CMS believes that providing more specific requirements to hospitals on what actions they must take prior to the patient’s discharge or transfer to a PAC setting will lead to improved transitions of care and patient outcomes.
CMS is proposing to revise the existing requirements in the form of six standards at §482.43. The following tables highlight the proposed requirements for each of the six standards.
Standard 1: Design (Proposed §482.43(a)) |
|---|
| Hospital medical staff, nursing leadership, and other pertinent services would be required to provide input in the development of the discharge planning process. |
| The discharge planning process must be specified in writing and reviewed and approved by the hospital’s governing body. |
| CMS indicates that they would expect hospitals to develop Discharge Planning Policies & Procedures (P&Ps) that would be periodically reviewed by the Hospital’s Governing body. |
Standard 2: Applicability (Proposed §482.43(b)) |
|---|
| Hospitals would be required to complete the discharge planning process for all of the following patient types: |
| Inpatients | All Inpatients |
Outpatients Certain categories, including but not limited to: | Patients receiving observation services |
| Patients who are undergoing surgery or other same-day procedures where anesthesia or moderate sedation is used |
| Emergency department patients who have been identified by a practitioner as needing a discharge plan |
| Any other category of outpatient as recommended by the medical staff, approved by the governing body and specified in the hospital’s discharge planning P&Ps |
| Note: This proposal would revise the current requirement at §482.43(a), which requires a hospital to identify those patients for whom a discharge plan is necessary. |
Standard 3: Discharge Planning Process (Proposed §482.43(c)) |
|---|
| §482.43(c) | Require that hospitals implement a discharge planning process to begin identifying, early in the hospitalization, anticipated post-discharge goals, preferences, and needs of the patient and begin to develop an appropriate discharge plan for patients identified in proposed §482.43(b)) |
| It would be required that the discharge plan be tailored to the unique goals, preferences, and needs of the patient. |
| §482.43(c)(1) | Combine two existing requirements, §482.43(b)(2) and §482.43(c)(1), into a single requirement at §482.43(c)(1) that would require a registered nurse, social worker, or other personnel qualified in accordance with the hospital’s discharge planning policy, coordinate the discharge needs evaluation and the development of the discharge plan. |
| §482.43(c)(2) | Requiring a hospital to begin to identify anticipated discharge needs for each applicable patient within 24 hours after admission or registration, and the discharge planning process is completed prior to discharge home or transfer to another facility and without unduly delaying the patient’s discharge or transfer. |
| If the patient’s stay was less than 24 hours, the discharge needs would be identified prior to the patient’s discharge home or transfer to another facility. |
| This policy would not apply to emergency-level transfers for patients who require a higher level of care. However, while an emergency-level transfer would not need a discharge evaluation and plan, we would expect that the hospital would send necessary and pertinent information with the patient that is being transferred to another facility. |
| §482.43(c)(3) | Require that a hospital’s discharge planning process ensure an ongoing patient evaluation throughout the patient’s hospital stay or visit to identify any changes in the patient’s condition that would require modifications to the discharge plan. |
| This proposed standard would expand upon the current regulation by requiring that the discharge evaluation be ongoing, during the patient’s hospitalization or outpatient visit, and that any changes in a patient’s condition that would affect the patient’s readiness for discharge or transfer be reflected and documented in the discharge plan. |
| Note: This proposal would retain the requirement set out at §482.43(c)(4) and re-designated it with clarifications at §482.43(c)(3) |
| §482.43(c)(4) | New Requirement:The practitioner responsible for the care of the patient be involved in the ongoing process of establishing the patient’s goals of care and treatment preferences that inform the discharge plan, just as they are with other aspects of patient care during the hospitalization or outpatient visit. |
| §483.43(c)(5) | Require, that as part of identifying the patient’s discharge needs, the hospital consider the availability of caregivers and community-based care for each patient, whether through self-care, follow-up care from a community-based providers, care from a caregiver/support person(s), care from post-acute health care facilities or, in the case of a patient admitted from a long-term care or other residential care facility, care in that setting |
| Require hospitals to consider the patient or caregiver’s capability and availability to provide the necessary post-hospital care. As part of the on-going discharge planning process, hospitals would identify areas where the patient or caregiver/support person(s) would need assistance, and address those needs in the discharge plan in a way that takes into account the patient’s goals and preferences. |
| We propose that hospitals consider the availability of and access to non-health care services for patients, which may include home and physical environment modifications including assistive technologies, transportation services, meal services or household services (or both), including housing for homeless patients. These services may not be traditional health care services, but they may be essential to the patient’s ongoing care post-discharge and ability to live in the community. |
We propose that hospitals must consider the following in evaluating a patient’s discharge needs, including but not limited to: - Admitting diagnosis or reason for registration;
- Relevant co-morbidities and past medical and surgical history;
- Anticipated ongoing care needs post-discharge;
- Readmission risk;
- Relevant psychosocial history;
- Communication needs, including language barriers, diminished eyesight and hearing, and self-reported literacy of the patient, patient’s representative or caregiver/support person(s), as applicable; Patient’s access to non-health care services and community-based care providers; and
- Patient’s goals and treatment preferences.
|
| Note: During the evaluation of a patient’s relevant co-morbidities and past medical and surgical history, CMS encourages providers to consider using their state’s Prescription Drug Monitoring Program (PDMP). |
| Note: This proposal would re-designate §482.43(b)(4) as §483.43(c)(5). |
| §482.43(c)(6) | New Requirement:The patient and the caregiver/support person(s) be involved in the development of the discharge plan and informed of the final plan to prepare them for post-hospital care. |
| Note: This proposed requirement provides the opportunity to engage the patient or caregiver/support person(s) (or both) in post-discharge-decision making and supports the current patient rights requirement at §483.13 in which the patient has the right to participate in and make decisions regarding the development and implementation of his or her plan of care. This proposed requirement clarifies our current expectation regarding engaging caregivers/support persons in evaluating and planning a patient’s discharge or transfer. |
| §482.43(c)(7) | New Requirement:Require that the patient’s discharge plan address the patient’s goals of care and treatment preferences. |
| Note: CMS would expect that the appropriate medical staff would discuss the patient’s post-acute care goals and treatment preferences with the patient, the patient’s family or their caregiver/support persons (or both) and subsequently document these goals and preferences in the medical record. We would expect these documented goals and treatment preferences to be taken into account throughout the entire discharge planning process. |
| §482.43(c)(8) | New Requirement:Require that hospitals assist patients, their families, or their caregiver’s/support persons in selecting a PAC provider by using and sharing data that includes but is not limited to HHA, SNF, IRF, or LRCH data on quality measures and data on resource use measures. |
| The hospital would have to ensure that the PAC data is relevant and applicable to the patient’s goals of care and treatment preferences. |
| CMS would expect the hospital to document the measures shared with the patient and uses to assist the patient during the discharge planning process in the medical record. |
| As required by the IMPACT Act, hospitals must take into account data on quality measures and data on resource use measures of PAC providers during the discharge planning process. |
| Note: CMS would expect that the hospital would be available to discuss and answer patients and their caregiver’s questions about their post-discharge options and needs. |
| §482.43(c)(9) | Require that the patient’s discharge needs evaluation and discharge plan be documented and completed on a timely basis, based on the patient’s goals, preferences, strengths, and needs, so that appropriate arrangements for post-hospital care are made before discharge. |
| All relevant patient information would be incorporated into the discharge plan to facilitate its implementation and the discharge plan must be included in the patient’s medical record. |
| The results of the evaluation must also be discussed with the patient or patient’s representative. |
| Note: CMS believes that in response to this requirement, hospitals would establish more specific time frames for completing the evaluation and discharge plans based on the needs of their patients and their own operations. |
| Note: This proposal would re-designate and revise the current requirement at §482.43(b)(5) at new §482.43(c)(9). |
| §482.43(c)(10) | Require hospitals to assess its discharge planning process on a regular basis. |
| Require that the assessment include ongoing review of a representative sample of discharge plans, including patients who were readmitted within 30 days of a previous admission, to ensure that they are responsive to patient discharge needs. |
| Note: CMS believes the evaluation can be incorporated into the Quality Assessment and Performance Improvement (QAPI) process, although we have not explicitly required this coordination and solicit comments on doing so. |
| Note: This proposal would re-designate and revise the current requirement at §482.43(e) at new §482.43(c)(10) |
Standard 4: Discharge to Home (Proposed §482.43(d)) |
|---|
| §482.43(d) | Require that the discharge plan include, but not be limited to, discharge instructions for patients describe in proposed §482.43(b) in order to better prepare them for managing their health post-discharge. |
| The phrase “patients discharged to home” would include, but not be limited to, those patients returning to their residence, or to the community if they do not have a residence, who require follow-up with their primary care provider (PCP) or a specialist; HHAs; hospice services; or any other type of outpatient health care service. |
| The phrase “patients discharged to home” would not refer to patients who are transferred to another inpatient acute care hospital, inpatient hospice facility or a SNF. |
| Note: This proposal would re-designate and revise the current requirement at §482.43(c)(5) which currently requires that as needed, the patient and family or interested persons be counseled to prepare them for post-hospital care. |
| §482.43(d)(1) | Require that discharge instructions must be provided at the time of discharge to patients, or the patient’s caregiver/support person(s), (or both) who are discharged home or who are referred to PAC services. |
| Require practitioners/facilities (such as a HHA or hospice agency and the patient’s PCP), receive the patient’s discharge instructions at the time of discharge if the patient is referred to follow up PAC services. |
| Note: CMS would expect that discharge instructions would be carefully designed to be easily understood by the patient or the patient’s caregiver/support person (or both)… In addition, as a best practice, hospitals should confirm patient or the patient’s caregiver/support person’s (or both) understanding of the discharge instructions. We recommend that hospitals consider the use of “teach-back” during discharge planning and upon providing discharge instructions to the patient. |
| §482.43(d)(2) | Clarify the current requirement at §482.43(c)(5) to require hospitals to provide instruction to the patient and his or her caregivers about care duties that they will need to perform in the patient’s home. Instruction would be based on the specific needs of the patient as determined in the patient’s discharge plan. |
| §482.43(d)(2)(ii) | New Requirement:Require that the discharge instructions include written information on the warning signs and symptoms that patients and caregivers should be aware of with respect to the patient’s condition. |
| The written information would include instructions on what the person should do if these warning signs and symptoms present. |
| Furthermore, the discharge instructions would include information about who to contact if these warning signs and symptoms present. |
| §482.43(d)(2)(iii) | Require that the patient’s discharge instructions include all medications prescribed and over-the counter for use after the patient’s discharge from the hospital. |
| This should include a list of the name, indication, and dosage of each medication along with any significant risks and side effects of each drug as appropriate to the patient. |
§482.43(d)(2)(v) | New Requirement:Require that that patient’s medications be reconciled. |
| In the context of this proposed rule, medication reconciliation would include reconciliation of the patient’s discharge medication(s) as well as with the patient’s pre-hospitalization/visit medication(s) (both prescribed and over-the-counter); comparing the medications that were prescribed before the hospital stay/visit and any medications started during the hospital stay/visit that are to be continued after discharge, and any new medications that patients would need to take after discharge. |
| We would expect that any medication discrepancies (omissions, duplications, conflicts) would be corrected as part of the medication reconciliation process. |
| We are proposing that all patients have an accurate medication list prior to hospital discharge or transfer. The actual process used for medication reconciliation might vary among hospitals. |
| We would expect the medication reconciliation process to consider how patients would obtain their post-discharge medications. |
| CMS Soliciting Comments: As part of the medication reconciliation process, we encourage practitioners to consult with their state’s PDMP. In section II.A.3 of this proposed rule we discuss the potential benefits as well as the challenges associated with the use of PDMPs. Given these potential benefits and challenges, we are soliciting comments on whether, as part of the medication reconciliation process, practitioners should be required to consult with their state’s PDMP to reconcile patient use of controlled substances as documented by the PDMP, even if the practitioner is not going to prescribe a controlled substance. |
| New Requirement at §482.43(d)(2)(v):Require that written instructions, in paper or electronic format (or both), would be provided to the patient, and that the instructions would document follow-up care, appointments, pending and/or planned diagnostic tests, and any pertinent telephone numbers for practitioners that might be involved in the patient’s follow-up care or for any providers/suppliers to whom the patient has been referred for follow-up care…The major elements of any follow-up care would be required to be written so that the patient, caregiver/support person can refer to them post-hospitalization. |
| The choice of format of the instructions should be based on patient and caregiver needs, preferences, and capabilities. |
| §482.43(d)(3) | Require that the hospital send the following information to the practitioner(s) responsible for follow up care, if the practitioner has been clearly identified: |
- A copy of the discharge instructions and the discharge summary within 48 hours of the patient’s discharge;
- Pending test results within 24 hours of their availability;
- All necessary information as specified in proposed §482.43(e)(2)
|
| |
| |
| §482.43(d)(4) | New Requirement: require, for patients discharged to home, that the hospital must establish a post-discharge follow-up process. |
Standard 5: Transfer of Patients to Another Health Care Facility
(Proposed §482.43(e)) |
|---|
| We propose to re-designate and revise the standard currently set out at §482.43(d) as §482.43(e), “Transfer of patients to another health care facility,” by clarifying our expectations of the discharge and transfer of patients. |
| We would continue to require that all hospitals communicate necessary information of patients who are discharged with transfer to another facility. The receiving facility may be another hospital (including an inpatient psychiatric hospital or a CAH) or a PAC facility. |
| We do not propose to mandate a specific transfer from. However, we do propose to clarify our expectations regarding what constitutes the necessary medical information that must be communicated to a receiving facility to meet the patient’s post-hospitalization health care goals, support continuity in the patient’s care, and reduce the likelihood of hospital readmission. |
| Proposed Minimum Information to be provided to a Receiving Facility | Demographic information, including but not limited to name, sex, date of birth, race, ethnicity, and preferred language; |
| Contact information for the practitioner responsible for the care of the patient and the patient’s caregiver/support person(s); |
| Advance directive, if applicable; |
| Course of illness/treatment; |
| Procedures; |
| Diagnoses; |
| Laboratory tests and the results of pertinent laboratory and other diagnostic testing; |
| Consultation records; |
| Functional status assessment; |
| Psychosocial assessment, including cognitive status; |
| Social supports; |
| Behavioral health issues; |
| Reconciliation of all discharge medications with the patient’s pre-hospital admission/registration medications (both prescribed and over-the-counter); |
| All known allergies, including medication allergies; |
| Immunizations; |
| Smoking status; |
| Vital signs; |
| Unique device identifier(s) for a patient’s implantable device(s), if any; |
| All special instructions or precautions for ongoing care, as appropriate; |
| Patient’s goals and treatment preferences; and |
| All other necessary information to ensure a safe and effective transition of care that supports the post-discharge goals of the patient. |
| Note: CMS is soliciting comments on these proposed medical information requirements. |
| In addition to these proposed minimum elements, necessary information must also include a copy of the patient’s discharge instructions, the discharge summary, and any other documentation that would ensure a safe and effective transition of care, as applicable. |
| Additionally, we propose that the requirement and the timeframe for communicating necessary information for patients being transferred to another healthcare facility remain the same as in the current requirement. That is, hospitals would continue to be required to provide this information at the time of the patient’s discharge and transfer to the receiving facility. |
Standard 6: Requirements for Post-Acute Care Services (Proposed §482.43(f)) |
|---|
| We propose to re-designate and revise the requirements of current §482.43(c)(6) through (8) at new §482.43(f), “Requirements for post-acute care services.” |
| The current regulation directs hospitals to provide a list of available Medicare-participating HHAs or SNFs to patients for whom home health care or PAC services are indicated. |
We are proposing that for patients who are enrolled in Managed Care Organizations, the hospital must: | Make the patient aware that they need to verify the participation of HHAs or SNFs in their network. |
| If the hospital has information regarding which providers participate in the managed care organization’s network, it must share this information with the patient. |
| The patient or their caregiver/support persons must be informed of the patient’s freedom to choose among providers and to have their expressed wishes respected, whenever possible. |
| The final component of the retained provision would be the hospital’s disclosure of any financial interest in the referred HHA or SNF. However, this section would be revised to include IRFs and LTCHs. |
Considerations for Hospitals
While not all inclusive, should this Proposed Rule be finalized, here are some things to think about and questions that will need to be asked and answered.
- These proposals will require collaboration from several professionals/departments within the Hospital (Hospital Medical Staff, Nursing Leadership, Case Management, Social Services, Quality, IT, Pharmacy, Physical and Occupational Therapy, Dietician).
- Issues to think about if this Proposed Rule is Finalized:
- What is our current Policy and Procedure for Discharge Planning?
- How are we going to incorporate Discharge Planning for the Outpatient Population?
- Standard 3: Discharge Planning Process (Proposed §482.43(c)(1)) “would require a registered nurse, social worker, or other personnel qualified in accordance with the hospital’s discharge planning policy, to coordinate the discharge needs evaluation and the development of the discharge plan.” Does our discharge planning policy identify the professionals that can initiate this process?
- Where do we find and who in the hospital would be involved in providing data on Quality Measures and Data on Resource Measures to the patient, their families, or their caregiver’s/support person?
- For those interested in learning more about the IMPACT Act, CMS held an MLN Connects® National Provider Cal regarding the IMPACT Act of 2014 and Data Standardization. The slide presentation can be accessed at https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2015-10-21-Post-Acute-Care-Presentation.pdf . CMS also has a webpage dedicated to information about the IMPACT Act and Cross Setting Measures at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014-and-Cross-Setting-Measures.html.
- Related to §482.43(d)(3), who would be responsible for sending follow-up information to the practitioner(s) responsible for follow-up care? How would you ensure a discharge summary be available within 48 hours of the patient’s discharge?
- Who will be responsible for the post-discharge follow-up process for patients being discharged to home? What will this process look like?
While, this article highlights proposals specific to Hospital Discharge Planning be mindful that this proposed rule also includes:
- Proposals for Home Health Agency Discharge Planning;
- Information Collection Requirements (ICRs) for hospital, HH and CAH discharge planning; and
- A Regulatory Impact Analysis.
MMP strongly encourages key stakeholders within your facility to read the proposed rule and submit comments. CMS has provided four was to submit comments. This information can be found on pages 1-3 of the display copy of the Proposed Rule.
Resources
Link to CMS Press Release – Discharge Planning Proposed Rule Focuses on Patient Preferences:
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-10-29.html
Link to display copy of Proposed Rule: https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-27840.pdf
This document was scheduled to be published in the Federal Register on 11/03/2015 and available online at http://federalregister.gov/a/2015-27840. There is a 60 day comment period on the proposed rule.
Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.
