Here are laws defining the process
Discharge planning is the law. As an access manager integrally involved in the discharge process, you knew that, right? Or maybe not.
Giving a presentation at a national meeting in Las Vegas recently on the rules and realities of discharge planning, veteran discharge planning and case management consultant Jackie Birmingham, RN, MS, CMAC, was shocked to discover that many in her audience did not know there were laws mandating discharge planning. This was true even of those managing case management or discharge planning departments, notes Birmingham, who is vice president of professional services for Curaspan Inc. in Newton, MA.
What Birmingham came to realize, she says, is that this phenomenon was a function of the widespread hospital re-engineering efforts of the 1990s, during which many organizations decentralized services and laid-off middle managers.
When hospital administrators noticed that the changes resulted in less-desirable patient outcomes, including longer lengths of stay, they reestablished discharge planning departments, but put people in charge who had no discharge planning legacy, Birmingham explains. "So [the managers] are doing the right thing, but have no idea why they’re doing it."
With that in mind, she has taken on the mission of disseminating information on the laws that support discharge planning. The major impetus for discharge planning and case management, Birmingham notes, can be found in the following laws, which are listed with her interpretation of their provisions:
• Social Security Act (SSA)
As stated in the Conditions of Participation for Hospitals (Federal Register, Dec. 19, 1997), the SSA makes a number of provisions regarding discharge planning. It directs health care providers to:
— identify patients who need discharge planning;
— provide an evaluation for patients;
— evaluate patients on a timely basis to ensure appropriate plans;
— include an evaluation of need for post-hospital services, including hospice;
— include an evaluation in the medical record and discuss results with the patient and/or the patient’s representative;
— develop an initial implementation of the plan;
— develop the plan under the supervision of a registered nurse, social worker or other qualified person.
• SSA Amendment (Utilization Review)
This amendment came about a few years after the establishment of Medicare sparked an increase in the usage of health care, Birmingham explains. "Utilization review was mandated because this was the first time there had been coverage for medical care and the utilization of services and the cost of the program were beyond what had been expected."
The government decided to start evaluating the quality and outcome of the services it was paying for, to be sure there was appropriate care for patients, she adds.
• Tax Equity and Fiscal Responsibility Act of 1982
This act, which applies only to inpatients, changed the way Medicare reimbursed hospitals, looking at groups of diagnoses and paying according to length of stay and cost per case, Birmingham says. "That’s when discharge planning became critical, because if hospitals began to discharge patients earlier, there needed to be a way to plan for patients who were leaving quicker and sicker.’"
A process was needed to connect the post-acute providers with patients with more medical care needs, she adds.
• Emergency Medical Treatment and Labor Act
Passed in 1987, this legislation — often referred to as the "anti-dumping law" — specifies that a patient cannot be discharged or transferred from an emergency department until he or she is stabilized. "Stabilization," Birmingham points out, means that no significant medical deterioration is likely after the patient is discharged or transferred, and it is judged on professional standards of practice, not on the hospital standard.
A "nonstabilized" patient, she continues, may be transferred only when the medical benefits outweigh the risks, the patient (or family) consents, and there is medical treatment by the transferring hospital to minimize risk during transfer. The receiving hospital must agree to the transfer, all medical records must be sent, and the transfer must be accomplished with qualified personnel and equipment, Birmingham adds.
• Preadmission Screening and Annual Resident Review (PASARR)
Another 1987 piece of legislation, the PASARR was passed to ensure that patients who have mental health needs are identified before admission to a nursing home, she says. It addresses the issue of whether patients being admitted to a skilled nursing facility have the medical/nursing needs to warrant the admission.
• Medicare as Secondary Payer (MSP)
The MSP rules, passed in 1990, state that Medicare will not be the primary payer when another payer is available, such as when a patient’s spouse is employed and has insurance coverage, when the treatment is the result of an automobile accident for which there is insurance coverage, or when worker’s compensation applies.
Providers must review the MSP rules for every admission, as well as for outpatient cases and laboratory tests, Birmingham notes. Hospitals are liable for recovery of money for up to 10 years after the admission or service.
• Health Insurance Portability and Accountability Act (HIPAA) of 1996
This legislation, for which regulations still are being written, also burdens those involved in discharge planning with needing to know as much about laws as they do about diseases, Birmingham says. The privacy section of HIPAA will impact how referrals are made and how information about patients is transferred from one level of care to another, she adds, as well as what will need to be documented even about referral sources that don’t take the patient.
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