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Centers for Medicare & Medicaid Services New Interpretive Guidelines for the Conditions of Participation for Discharge Planning Part 1
Toni Cesta, PhD, RN, FAAN
Introduction The Discharge Planning Process
The Conditions of Participation (CoP) for discharge planning were adopted in 1994. This year, 2013, The Centers for Medicare & Medicaid Services (CMS), have updated these guidelines and clarified some of the language. The clarifications are called "interpretive guidelines." CMS is clear to say that hospitals are not bound to the interpretative guidelines and that they are for informational purposes only. As case managers, it is critical that you and your fellow staff members are always up to date and informed concerning the CoP, particularly those components of the CoP most closely related to our roles as case managers. So in addition to the CoP for discharge planning, you should also familiarize yourself with the CoP for utilization review. However, this month we will be focusing on the CoP for discharge planning.
What is Discharge Planning?
Discharge planning is a process. As such, it begins on admission, or before admission, and continues until the patient has safely arrived at the next level of care. It is a process by which a systematic approach is used to facilitate the transition of the patient from one level of care to another as the patient’s condition and care needs change.
Medicare defines discharge planning as "a process used to decide what a patient needs for a smooth move from one level to another." (See www.cms.gov/cfcsandcops/.)
The process should include the following:
- admission assessment for initial discharge planning purposes;
- planning the stay from door to door;
- collaboratively determining level of care for post-discharge;
- re-assessment daily;
- connecting patient to post-acute services;
- final assessment;
- transitioning patient to the next level of care.
As with other case management processes, we must remember that the process is not always linear. Sometimes steps in the process may need to be repeated as the patient’s needs and condition change. This is particularly true for the discharge planning process. In fact, the guidelines clearly state that changes in the patient’s condition may warrant a new discharge plan, or a change to the existing discharge plan. For this reason, your hospital must have a policy and procedure that addresses how the discharge planning staff will be made aware of changes in the patient’s condition that may warrant a change to the discharge plan. This supports case management best practice, which recommends that every patient be re-assessed daily.
Interpretive Guidelines
CMS released an update of Appendix A of the State Operations Manual. This update provided revised interpretive guidelines for the discharge planning CoP at 42 CFR 482.43, discharge planning. If you are interested in reading the entire document, you can find it at www.cms.gov/cfcsandcops/.
The new interpretive guidelines use language not seen before in the CoP for discharge planning. Care transitions as a concept is new to the CoP and a welcomed addition. While CMS continues to use the term "discharge planning," it makes note of the fact that the newer language of "transition planning" or "community care transitions" may be preferred by some. This preference, particularly in case management, addresses the idea that patient transitions occur among multiple types of patient care settings that may be included in the care of patients across the continuum.
Interpretive Guidelines for 42 CFR 482.3
"The hospital must have in effect a discharge planning process that applies to all patients. The hospital’s policies and procedures must be specified in writing."
CMS is making the distinction in the statement above that all patients must have the discharge planning process applied to them, not just Medicare patients. While this specifically applies to inpatients being discharged from the hospital, CMS comments that similar processes should be developed for ambulatory surgery, observation and similar patients treated at an outpatient level of care.
The interpretive guidelines also make mention of "readmissions" in this section. CMS comments that "when discharge planning is well executed," the patient proceeds toward the goal of his or her plan of care after discharge. In other words, the patient continues to recover outside the hospital, and in the most appropriate setting. CMS acknowledges that some patients may be readmitted within thirty days, and that this may, in some circumstances, be unavoidable. By making this statement, they acknowledge that even under the best of circumstances, some patients will return to the hospital within thirty days.
Concerning Readmissions
The guidelines support and suggest that hospitals be well-advised to assume that every inpatient requires a discharge plan to reduce the risk of adverse health consequences post-discharge. This would include a readmission to the hospital. They go on to say that screening processes may result in some patients being missed for the purposes of discharge planning. Best practice case management models support this approach. Every patient should be assessed by a case manager and should be followed for the purposes of discharge planning, among other things.
It is important to note that not every patient’s discharge plan will be a complex plan. Some patients may need nothing more than clear instructions on how to care for themselves at home. If this is the best plan for your patient, then this is what should be documented in the medical record. By documenting this, you are demonstrating that you assessed the patient and his or her plan for discharge was addressed and considered. A note that simply states "no discharge needs identified" is inadequate and does not reflect the case management process.
Screening Patients for Discharge Planning Needs
The interpretive guidelines also explain that, if your hospital does not case manage every patient, then you must have a policy and procedure that documents the criteria and screening process you use to identify patients that are likely to need discharge planning. Since discharge planning is such a fluid process, this will be hard to support in your policies. You will have to include the basis for the screening criteria that you are using, and the actual screening process itself. You must also identify the staff that are responsible for conducting the screening process by title.
The guidelines do not mandate the timeframe for when the identification of the patient’s discharge needs should take place. Obviously, from a case management perspective, this should be as soon after admission as possible. The guidelines go on to say that, when the process cannot be conducted early in the stay, it should be completed at least 48 hours prior to discharge when at all possible, assuming that the late assessment did not result in a delay in the discharge process. A delay would be interpreted as a delay in placing the patient in the next appropriate setting, due to a process delay on the part of the hospital.
Survey Procedures
The following are recommended procedures that you can carry out in your department to ensure that you are compliant with the issues we have just reviewed.
• In hospitals that do not require that every patient be given a discharge evaluation (assessment), is there a timely screening to determine if a discharge planning evaluation is needed?
• Was the screening done to
identify patients needing a discharge planning evaluation?
Is the hospital in compliance with conducting this greater than 48 hours prior to discharge?
For patients whose length of stay is less than 48 hours, is there evidence of a screening done?
• Can staff demonstrate that the hospital’s criteria for screening is correctly applied?
• If the patient doesn’t initially have any identified discharge needs, can you demonstrate that there is a process for updating the patient’s condition or circumstances?
• Does your policy have a process for an evaluation of a patient that did not initially have an identified discharge need?
• Are inpatient staff aware of who and how to notify if the patient’s condition changes in a way that requires a change to the discharge plan?
482.43(b) Standard: Discharge Planning Evaluation
This standard states
"1. The hospital must provide a discharge planning evaluation to the patients identified in paragraph (a) of this section, and to other patients upon the patient’s request, the request of a person acting on the patient’s behalf, or the request of the physician.
***
"3. The discharge planning evaluation must include an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services.
"4. The discharge planning evaluation must include an evaluation of the likelihood of a patient’s capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital."
Interpretive Guidelines for 482.43(b), 1, 3, and 4
For this standard, every patient that is identified as a potential risk for an adverse outcome, should they not have a discharge plan, must have one completed. Unless your hospital’s policy is to evaluate every patient for the purposes of discharge planning, the hospital must provide a discharge plan if the patient, physician, or patient’s representative requests one. Patients must be notified that this option is available to them and this should be documented in the medical record. Even if the patient does not meet the screening criteria, you must provide discharge planning if requested.
Interpretive Guidelines for 482.43 (b) (4)
This section requires that the evaluation include an assessment of the patient’s capacity for self-care. If this is not possible, then an assessment of how the patient will be cared for by others must be included. CMS suggests that the best discharge goal for patients is to return them to their prior living situation whenever possible.
As we discussed earlier, these guidelines require that a thorough assessment be done on your patients and that this assessment be as comprehensive as possible. In your assessment you should consider what the patient’s immediate care needs will be, but you must also project beyond the immediate post-discharge period. In your assessment you should consider whether the patient’s current clinical state will remain constant or diminish over time. You must also consider whether the patient’s residence can support his or her post-hospital clinical needs. Your assessment must consider whether the patient may need specific durable medical equipment in the home as well as any other special needs the patient may have.
Interpretive Guidelines for 482.43 (b) (3)
This section discusses the likelihood of the patient and family being able to manage their post-discharge needs as well as the availability of those needed services.
As case managers, we must evaluate and provide for any community-based services that the patient may need in order for them to continue living at home.
Such services include
- home health, attendant care;
- hospice or palliative care;
- respiratory care;
- rehabilitation services including physical, speech and occupational therapy;
- end-stage renal dialysis services;
- pharmaceuticals and related supplies;
- nutritional consultation and /or supplemental diets;
- medical equipment and related supplies.
- Less traditional services include
- home and physical environment modifications;
- transportation services;
- meal services;
- household services such as housekeeping or shopping.
Each of these potential categories should be included in your assessment form.
Other issues to consider would include a follow-up appointment with the patient’s primary care doctor, surgeon or specialist, or a series of appointments for physical or occupational therapy. It is recommended that in your role as a case manager, you facilitate the making of these appointments and not leave them up to the patient alone. Patients may not make the appointments in a timely manner, and this may result in a return to the emergency department or an unnecessary admission to the hospital. For these reasons, case managers must project beyond the immediate discharge while considering the patient’s capacity for self-care, including making and keeping appointments.
Our goal as case managers is to always consider the level of care that meets the patients’ needs with the goal of keeping the patient at home whenever possible. If this is not possible, then transfer to a facility may be necessary. This transfer may be for a short period of time or may be a permanent placement.
Involving the Patient and Family
As case managers, we are expected to have knowledge of the capabilities and capacities of the long-term care facilities that we refer patients to. In addition, we must discuss the possibility of any out-of-pocket expenses with the patient and/or family. We are required to have a general knowledge of the terms of a patient’s insurance, particularly as to how this relates to the availability of post-acute services for the patient. Should the needed post-acute services not be covered by the patient’s insurance plan, then this financial liability must be discussed with the patient and family. Should the patient not want to, or be unable to pay out of pocket for the services, then alternative arrangements must be made.
The CoP also provides that the patient has the right to participate in the development and implementation of his or her plan of care. As case managers, we should always include the patient and/or family in the discharge planning process from the beginning of the stay onward. In addition to providing choice in the selection of post-acute services, CMS requires that we incorporate the patient’s goals and preferences into the evaluation as much as possible. As case managers, we must develop a relationship with the patient and family from day one of the hospital stay. Discharge planning cannot be conducted from the chart and in the absence of the patient. By working directly with the patient and family, we have a much higher likelihood of developing a successful discharge plan that will result in a successful outcome.
Interpretive Guidelines for 482.43 (b)(2)
This section states that a registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise, the development of the evaluation.
Your department’s policies and procedures should specify the qualifications needed to be a discharge planner in your hospital. Qualifications should include the following:
- previous experience in discharge planning or training in discharge planning;
- knowledge of clinical and social factors that affect the patient’s functional status at discharge;
- knowledge of community resources to meet post-discharge clinical and social needs;
- assessment skills;
- insurance/financial factors to be considered in development of a discharge plan;
- physical factors to be considered in development of a discharge plan.
Interpretive Guidelines for 484.43 (b)(5)
This section states that hospital personnel must complete the evaluation on a timely basis so that appropriate arrangements for post-hospital care are made before discharge, and to avoid unnecessary delays in discharge.
While CMS does not stipulate the exact time frame for completing the initial discharge planning assessment, it does indicate that it should be done in a time frame that allows completion of arrangements without delay in the patient’s inpatient stay. Because the national average length of stay is fairly short, this means that the process should begin as soon after admission as possible. The process should be collaborative, including the entire interdisciplinary care team. As discussed earlier, reassessment should occur daily so that changes in the patient’s clinical condition can be taken into account while developing the discharge plan.
Next month we will continue reviewing the interpretative guidelines for the CoP for discharge planning.
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