EXECUTIVE SUMMARY
Hospital providers voice concerns about a proposed rule by the Centers for Medicare and Medicaid Services (CMS) that would require providers to devote more resources to discharge planning. The rule would apply to inpatients as well as emergency patients requiring comprehensive discharge plans as opposed to discharge instructions. CMS states that the rule would ensure the prioritization of patient preferences and goals in the discharge planning process, and also would prevent avoidable complications and readmissions. However, hospital and emergency medicine leaders worry that community resources are not yet in place to facilitate the links and follow-up required in the proposed rule, and that the costs associated with implementation would be prohibitive.
- The proposed rule would apply to acute care hospitals, EDs, long-term care facilities, inpatient rehabilitation centers, and home health agencies. Regardless of the setting, though, CMS is driving home the message that patient preferences should be given more weight during the discharge planning process.
- Under the rule, hospitals or EDs would need to develop a patient-centered discharge plan within 24 hours of admission or registration, and complete the plan prior to discharge or transfer to another facility.
- Under the rule, emergency physicians would determine which patients require a comprehensive discharge plan.
- Both the American Hospital Association and the American College of Emergency Physicians worry that hospitals will have to take on more staff, invest in training, and make changes to their electronic medical record systems to implement the provisions in the proposed rule.
The Centers for Medicare and Medicaid Services (CMS) is projecting clear signals that hospital providers soon will need to devote more resources to the discharge planning process. The agency spelled out its intentions in a proposed rule designed to ensure that patients who are discharged from the hospital or the ED have clear follow-up instructions and that they are connected with appropriate resources and follow-up. In addition to acute care hospitals and EDs, the proposed requirements would apply to long-term care facilities, inpatient rehabilitation centers, and home health agencies. Regardless of the setting, CMS is driving home the message that emergency medicine clinicians should give more weight to patient preferences during the discharge planning process.
When announcing the rule, Patrick Conway, MD, deputy administrator and chief medical officer at CMS, said that the rule will put the patient and caregivers at the center of care delivery.
“Patients will receive discharge instructions, based on their goals and preferences, that clearly communicate what medications and other follow-up is needed after discharge, and pertinent medical information will be communicated to providers who care for the patient after discharge,” he said. “This leads to better care, smarter spending, and healthier people.”
According to CMS, the proposed revisions would update the requirements for discharge planning, making them more consistent with current practice. The agency also stated that the new provisions would improve care and outcomes while reducing adverse events and readmissions.
In addition, the proposed rule would implement the discharge planning provisions within the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), which requires hospitals as well as some post-acute care providers to focus on patient preferences during the discharge planning process, and to leverage data on both quality and resource use in their efforts to help patients reach their goals.
However, the proposed rule, which was posted in the Federal Register on Nov. 3, 2015 (http://federalregister.gov/a/2015-27840), has sparked strong reactions from hospital providers who maintain that the new requirements will be too expensive to implement. For instance, while agreeing with CMS’ goal for hospitals to deploy comprehensive, multidisciplinary, patient-centered discharge planning processes, the American Hospital Association (AHA) stated that hospitals would likely need to take on additional staff, develop and implement new discharge planning processes, and make changes to their electronic medical records (EMR) systems. The AHA added that such changes would be particularly onerous for community hospitals, many of which operate under very tight budgets.
The American College of Emergency Physicians (ACEP) largely agreed with AHA’s position, noting that regulators need to be mindful of the many demands on providers already in place.
“This is just one of many, many documentation requirements and regulations that have come out of this administration since the passage of the Affordable Care Act (ACA),” observes Barbara Tomar, MHA, federal affairs director at ACEP in Washington, DC. “
Train more social workers
Specifically, among the provisions contained in the proposed rule, hospitals would be required to do the following for applicable patients:
- develop a patient-centered discharge plan within 24 hours of admission or registration, and complete the plan prior to discharge or transfer to another facility;
- establish a medication reconciliation process that aims to improve medication management and patient safety;
- send relevant medical information to the receiving facility in the case of patient transfers;
- create a post-discharge follow-up process.
The proposed requirements would have a particular effect on inpatient populations, but they would also affect many ED patients. For instance, for the 30% of hospitals that have dedicated ED-based observation units, patients discharged from those units would clearly require comprehensive discharge plans under the proposed rule, explained Tomar. In addition, while the rule isn’t entirely clear on this point, complex patients or patients with multiple comorbidities would likely require comprehensive discharge plans as well.
“It sounds like for the purposes of the ED that the physician would identify patients who should have more comprehensive discharge plans as opposed to discharge instructions,” Tomar says.
However, given that EDs operate 24 hours a day, seven days a week, EDs would need to make social workers available on weekends and after hours to complete the comprehensive discharge plans, notes Tiffany Jackson, MD, an emergency medicine physician at the University of Alabama in Birmingham.
“Then we would also need those community resources that [patients] would reach out to 24 hours a day,” she says. “We need to have ways to get patients back into the community, get them plugged in, and to coordinate care, but unfortunately I believe that the infrastructure is not ready yet.”
Jackson adds that hospitals would have a tough time finding the staff to implement the comprehensive discharge planning goals implied in the proposed rule.
“Even if we did have all this money to pay for social workers, there is not even a workforce of social workers that could fill all the needs throughout the country, so there are a lot of infrastructure issues that would need to be addressed,” she explains.
Of particular concern to emergency providers, the proposed rule appears to put them on the hook for patients with complex behavioral health needs who arrive in the ED when there is nowhere else to go.
“The housing of psych patients is a big problem across a lot of hospital EDs, and the lack of placement is a big issue, so they just back up in the ED,” Tomar stresses. “Clearly [these patients] would be the kind of patients who would need some sort of structured plan, but all the plans in the world aren’t going to guarantee that there is a way to implement them.”
Jackson agrees with these sentiments, particularly for those patients requiring inpatient mental healthcare.
“If there is no bed for these patients, we can try our best to create a plan, but ultimately what they need is a bed,” she adds.
Consider PDMP limitations
CMS is soliciting comments on the use of prescription drug monitoring programs (PDMPs). In particular, the agency wants to know whether the use of PDMPs should be mandated as part of the discharge planning process, and whether PDMPs should be used in the medication reconciliation process.
Noting that the functionality of PDMPs varies widely from state to state, Tomar says that ACEP believes that the use of PDMPs should not be mandated — at least not yet.
“Some of those systems are tied into hospital EMRs [so that] the information is pushed into the records. In other states, the PDMPs aren’t updated very frequently, and [providers] basically have to stop what they are doing in the ED, go to another computer, and log in [to access the PDMP information],” she explains. “It is very cumbersome in certain states, so we don’t want to see [PDMP use] mandated until it is at a level across the [country] that makes PDMPs useful and easy to access.”
It is unclear at this point when CMS might unveil final rulemaking on discharge planning.
“With rules like these, the feds have a lot more leeway to finalize them at their own pace,” Tomar observes. For instance, she notes that some draft rules issued in 2011 were only recently finalized.
“On the other hand, this could be something that the Obama administration wants to push through before they are out of office,” Tomar offers. “It is on the horizon, but until [CMS] starts to move to interpretive guidelines, it is hard to say what emergency providers should do.”
Tomar adds that in its current form, the proposed rule is more of an issue for inpatient providers than emergency medicine clinicians.
“We don’t really know what the endpoint is, or when this is going to be finalized,” she says.
SOURCES
- Tiffany Jackson, MD, Emergency Medicine Physician, University of Alabama, Birmingham, AL. Email: [email protected].
- Barbara Tomar, MHA, Federal Affairs Director, American College of Emergency Physicians, Washington, DC. Email: [email protected].
Emergency medicine clinicians are concerned that the infrastructure is not yet in place to facilitate successful implementation of proposed rule.
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