LeadingAge Comments on the Discharge Planning Process for Hospitals & Home Health

Members | October 28, 2015

LeadingAge submitted comments on the Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies proposed rule [CMS-3317-P] that revises the discharge planning requirements that hospitals, including long-term care hospitals and inpatient rehabilitation facilities, critical access hospitals, and home health agencies, must meet in order to participate in the Medicare and Medicaid programs.

LeadingAge submitted comments on the Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies proposed rule [CMS-3317-P] that revises the discharge planning requirements that hospitals, including long-term care hospitals and inpatient rehabilitation facilities, critical access hospitals, and home health agencies, must meet in order to participate in the Medicare and Medicaid programs. LeadingAge is pleased CMS would require the discharge planning process to apply to all inpatients, as well as certain categories of outpatients, including, but not limited to patients receiving observation services. We also applaud CMS for stating that hospitals need to include the availability of caregivers and community-based care for each patient in the discharge plan. 

LeadingAge recommends the following revisions to the requirement for discharge in the proposed rule:

  • Hospitals should be required to provide information to the patient regarding which providers participate in their managed care organization’s network. 
  • Hospitals should be required to notify patients of specialized programs offered by post-acute providers that may benefit the patient. For example, some home health agencies have specialized programs to care for individuals with CHF, COPD, and wound care. 
  •  CMS should revisit and revise their estimated implementation costs to reflect the additional time that will be needed to be in compliance with this regulation. 
  • The requirement to include resource use measures should be postponed until accessible, accurate data is available to acute and post- acute providers. 
  • CMS should instruct hospitals to provide the patient with PAC data on quality measures that are relevant and applicable to the patient's goals of care and treatment preferences, and not just give the SNF or Home Health Star rating. 
  • CMS should not include the requirement to provide data on quality measures and data on resource use measures for non-PAC providers at this time. 
  • CMS should expand the requirements for hospitals to identify the availability of caregivers and community based providers to include eligibility for Medicaid and Medicaid services, PACE and services through the Veterans Administration. 
  • CMS should accelerate the development of a modular certification program for long-term and post-acute care providers, and consider ways to encourage the adoption and use of these tools by rural and frontier providers to prevent this digital gap from further increasing.

The proposed changes would modernize the discharge planning requirements by: 

  • Implementing the discharge planning requirements of the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) by requiring hospitals, critical access hospitals, and certain post-acute care providers to use data on both quality and resource use measures to assist patients during the discharge planning process, while taking into account the patient’s goals of care and treatment preferences
  • Requiring hospitals and critical access hospitals to develop a discharge plan within 24 hours of admission or registration and complete a discharge plan before the patient is discharged home or transferred to another facility. This would apply to all inpatients and certain types of outpatients and emergency department patients who have been identified by a practitioner as needing a discharge plan
  • Hospitals and critical access hospitals would be required to consider the availability of non-health care services and community-based providers that may be available to patients post-discharge when evaluating a patient’s discharge needs.
  • CMS is 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.
  • Requiring hospital to assess its discharge planning process on a regular basis and 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. The evaluation can be incorporated into the Quality Assessment and Performance Improvement (QAPI) process, although they have not explicitly required this coordination and solicit comments on doing so.

Hospitals, critical access hospitals, and home health agencies would have to: 

  • Provide discharge instructions to patients who are discharged home (proposed for hospitals and critical access hospitals only).
  • Have a medication reconciliation process with the goal of improving patient safety by enhancing medication management (proposed for hospitals and critical access hospitals only).
  • For patients who are transferred to another facility, send specific medical information to the receiving facility.
  • Establish a post-discharge follow-up process (proposed for hospitals and critical access hospitals only).

Home Health Agencies specific provisions of the proposed rule CMS proposes:

  • HHAs be required to develop and implement an effective discharge planning process that focuses on preparing patients and caregivers/support person(s) to be active partners in post-discharge care, effective transition of the patient from HHA to post HHA care, and the reduction of factors leading to preventable re-admissions.
  • To establish a new standard, “Discharge planning process,” to require that the HHA’s discharge planning process ensure that the discharge goals, preferences, and needs of each patient are identified and result in the development of a discharge plan for each patient. 
  • To require that the HHA discharge planning process require the regular reevaluation of patients to identify changes that require modification of the discharge plan, in accordance with the provisions for updating the patient assessment at current §484.55. The discharge plan must be updated, as needed, to reflect these changes.
  • To require that the physician responsible for the home health plan of care be involved in the ongoing process of establishing the discharge plan. 
  • To require that the HHA consider the availability of caregivers/support persons for each patient, and the patient’s or caregiver’s capacity and capability to perform required care, as part of the identification of discharge needs.
  • To require that the evaluation of the patient’s discharge needs and discharge plan be documented and completed on a timely basis, based on the patient’s goals, preferences, and needs, so that appropriate arrangements are made prior to discharge or transfer.
  • To require that the evaluation be included in the clinical record. 
  • That the results of the evaluation be discussed with the patient or patient’s representative. Furthermore, all relevant patient information available to or generated by the HHA itself must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the patient’s discharge or transfer.
  • That as part of the medication reconciliation process, practitioners consult with their state’s Prescription Drug Monitoring Program. CMS is 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. CMS proposes to include these elements in the discharge plan so that there is a clear and comprehensive summary for effective and efficient follow-up care planning and implementation as the patient transitions from HHA services to another appropriate health care setting. 
  • At §484.58(b) to establish a new standard, “Discharge or transfer summary content,” to require that the HHA send necessary medical information to the receiving facility or health care practitioner. 

The information must include, at minimum, the following: 

  1. Demographic information, including but not limited to name, sex, date of birth, race, ethnicity, and preferred language;
  2. Contact information for the physician responsible for the home health plan of care; 
  3. Advance directive, if applicable; 
  4. Course of illness/treatment; 
  5. Procedures; 
  6. Diagnoses; 
  7. Laboratory tests and the results of pertinent laboratory and other diagnostic testing; 
  8. Consultation results; 
  9. Functional status assessment; 
  10. Psychosocial assessment, including cognitive status; 
  11. Social supports; 
  12. Behavioral health issues; 
  13. Reconciliation of all discharge medications (both prescribed and over-the-counter); 
  14. All known allergies, including medication allergies; 
  15. Immunizations; 
  16. Smoking status; 
  17. Vital signs; 
  18. Unique device identifier(s) for a patient’s implantable device(s), if any; 
  19. Recommendations, instructions, or precautions for ongoing care, as appropriate; 
  20. Patient’s goals and treatment preferences; 
  21. The patient’s current plan of care, including goals, instructions, and the latest physician orders; and 
  22. Any other information necessary to ensure a safe and effective transition of care that supports the post-discharge goals for the patient.

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. 

While CMS is not proposing a specific form, format, or methodology for the communication of this information for all facilities, CMS strongly believes that those facilities that are electronically capturing information should be doing so using certified health IT that will enable real time electronic exchange with the receiving provider. By using certified health IT, facilities can ensure that they are transmitting interoperable data that can be used by other settings, supporting a more robust care coordination and higher quality of care for patients.

The Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies proposed rule [CMS-3317-P] was published in the Federal Register on 11/03/2015