Presentation on theme: "Discharge Planning Providing the right care, at the right time, in the right setting."— Presentation transcript:
Discharge Planning Providing the right care, at the right time, in the right setting.
Purpose To provide classroom education on the role of case management in relationship to the discharge planning process.
Program Objectives Upon completion of this program, the participant will be able to: Define discharge planning. Discuss the rules, guidelines, and criteria pertaining to discharge planning. Identify the relationship between avoidable days, LOS, and denials and strategies to manage all three.
Program Objectives (Cont’d) Discuss the role the case manager plays within the interdisciplinary discharge planning team. Identify the types of continuum services available. List the common barriers to discharge planning.
Definition of Discharge Planning “A process used to decide what a patient needs for a smooth move from one level of care to another. This is done by a social worker or other health care professional. It includes moves from a hospital to a nursing home or to home care. Discharge planning may also include the services of home health agencies to help with the patient’s home care.” Centers for Medicare and Medicaid Services, glossary definition. www.cms.gov
Foundation of Discharge Planning Identification of needs by an interdisciplinary team. Define the least restrictive environment that can meet the patient’s needs. Always include patient and/or family in the discharge planning process.
Foundation of Discharge Planning (Cont’d) Educate the patient and family about community resources that can help them maintain their maximum potential and independence. Establish a safe discharge plan.
Key Concepts Know the rules and regulations pertaining to discharge planning. All patients need to be screened on admission for discharge planning needs. Key indicator for discharge planning – prior level of functioning.
Key Concepts (Cont’d) Continuous screening by Case Management during chart reviews. Open referral policy – physicians, patients, families, or any staff member.
Federal Regulations – Social Security Act § 1861 (ee) Discharge Planning Process: “The Secretary shall develop guidelines and standards for the discharge planning process in order to ensure a timely and smooth transition to the most appropriate type of and setting for post-hospital or rehabilitative care.” (Insert state statutes regarding discharge planning) www.ssa.gov
Federal Regulations - Social Security Act § 1861 (ee) (Cont’d) Discharge Planning Process Standards Hospitals must: Identify at an early stage of hospitalization those patients in need of discharge planning. Provide a discharge planning evaluation for those identified patients or upon request of patient, representative or physician. www.ssa.gov
Federal Regulations - Social Security Act § 1861 (ee) (Cont’d) Discharge Planning Process Standards (Cont’d) Hospitals must: Complete evaluation on a timely basis to ensure appropriate arrangements are in place before discharge to avoid unnecessary delays in discharge. www.ssa.gov
Federal Regulations - Social Security Act § 1861 (ee) (Cont’d) Discharge Planning Process Standards (Cont’d) Hospitals must: Include in evaluation patient’s likely need for appropriate post-hospital services and the availability of such services. Include the evaluation in the patient’s medical record and results must be discussed with the patient or representative. Arrange for the development and initial implementation of a discharge plan. www.ssa.gov
Federal Regulations - Social Security Act § 1861 (ee) (Cont’d) Discharge Planning Process Standards (Cont’d) Hospitals must: Develop plan by or under the supervision of a registered nurse, social worker, or other qualified personnel. Consistent with Section 1802 – not specify or limit qualified providers, identify any provider in which the hospital has a financial interest. www.ssa.gov
Federal Regulations - Social Security Act § 1861 (ee) (Cont’d) Discharge Planning Process Standards: Medicare+Choice For individuals enrolled with a Medicare+Choice organization/plan: “The discharge planning evaluation is not required to include information on the availability of home health services through individuals and entities which do not have a contract with the organization.” www.ssa.gov
Federal Regulations - Social Security Act § 1861 (ee) (Cont’d) Discharge Planning Process Standards: Medicare+Choice (Cont’d) For individuals enrolled with a Medicare+Choice organization/plan: “….the plan may specify or limit the provider (or providers) of post-hospital home health services or other post-hospital services under the plan.” www.ssa.gov
Federal Regulations - Social Security Act § 1861 (ee) (Cont’d) Applies only to patients who are admitted as inpatient. Not applicable for patients in the emergency department or outpatient, observation status. Includes: Medicare and Medicaid participating hospitals. Short-term psychiatric Rehabilitation Long-term, children’s, and alcohol/drug facilities.
Federal Regulations - Sec 482.43 Conditions of Participation: Discharge Planning: Standards Identification of needs Discharge planning evaluation Discharge plans Transfer or referral Re-assessment www.cms.gov, Hospital Conditions of Participation
Transfer Agreements A hospital and a skilled nursing facility shall have a written agreement between them for reasonable assurance that: “Transfer of patients will be effected between the hospital and SNF whenever such transfer is medically appropriate as determined by the attending physician.” Social Security Act § 1861 (l)
Transfer Agreements (Cont’d) “There will be interchange of medical and other information necessary or useful in the care and treatment of transferred patients between institutions or to help determine if patients can be adequately cared for in either institutions.” Social Security Act § 1861 (l)
Post Hospital Extended Care Services 3-Day Stay Rule A 3-day stay is mandatory for Medicare patients that require placement in a Skilled Nursing Facility (SNF) after their hospitalization. Counted by # of days the patient is in an inpatient status and in his/her bed at midnight. Observation days do not count as part of the 3 days. Section 1861 of the Social Security Act Federal Regulations 10116, 10118-19
Post Hospital Extended Care Services 3-Day Stay Rule This rule only applies to traditional Medicare and typically not Medicare replacement policies. There is an additional 30-day window for qualification if not discharged directly to a SNF. A 3-day stay is not needed if the patient is discharged to an Acute Care Rehab or Long Term Care Hospital. Section 1861 of the Social Security Act Federal Regulations 10116, 10118-19
Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) “75 Percent Rule” The Centers for Medicare and Medicaid (CMS) have instituted limits on the types of patients an acute inpatient rehab facility can accept. Section 1986 of the Social Security Act Federal Regulation 42 CFR 412.23(b)(2)
Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) “75% Rule” (Cont’d) 75% of their admits must have 1 of 13 diagnoses. (See listing on next page) 25% can be any diagnosis. It is the responsibility of the IRF to monitor the admission diagnosis to comply with the 75% rule. Section 1986 of the Social Security Act Federal Regulation 42 CFR 412.23(b)(2)
“75 Percent Rule” 13 Diagnoses Stroke Spinal Cord Injury Congenital Deformity Amputation Major multiple trauma Fracture of femur/hip Brain injury Neurological disorders Burns Active arthritis Systemic vasculidities Severe or advanced osteoarthritis Knee or hip joint replacement
Stark II Regulations Physician Self-Referral Law “Prohibits physicians from referring Medicare patients for certain designated health services (DHS) to an entity with which the physician or a member of the physician’s immediate family has a financial relationship unless an exception applies.” Examples: HHC, DME, outpatient therapies, laboratory, etc. (Insert hospital specific P&P relating to physician referrals.) Section 1877 of the Social Security Act 42 CFR Parts 411, 424
Post Acute Care (PAC) Transfer DRGs A transfer DRG plays an important role in payment when a patient with a qualified DRG is transferred to a post acute provider earlier than the geometric mean LOS. If a patient is admitted with a transfer DRG and is discharged before the geometric mean LOS, the hospital is paid using a transfer formula which decreases the overall payment to the hospital. Balanced Budget Act of 1997
Post Acute Care (PAC) Transfer DRGs (Cont’d) We only receive full DRG if the patient remains past the GM LOS. There are 182 transfer DRGs. (Insert Hospital Process) Balanced Budget Act of 1997
Emergency Medical Treatment and Active Labor Act (EMTALA) “Hospitals must provide medical screening examinations, treatments, and transfers of individuals with emergency medical conditions or women in labor regardless of the ability to pay. ” Section 1867 of the Social Security Act
Emergency Medical Treatment and Active Labor Act (EMTALA) (Cont’d) “An appropriate transfer should be initiated if the hospital is unable to stabilize the patient within its capability or if the patient requests.” Section 1867 of the Social Security Act
EMTALA Appropriate Transfers “The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual or unborn child’s health.” “The receiving facility has the appropriate space, capabilities, and qualified personnel for the treatment and has agreed to accept the transfer.” Section 1867 of the Social Security Act
EMTALA Appropriate Transfers (Cont’d) “The transferring hospital sends to the receiving hospital all medical records related to the emergency medical condition.” “The transfer is effected through qualified medical personnel, transportation and equipment.” Section 1867 of the Social Security Act
Preadmission Screening and Residential Review (PASRR) The PASRR is an assessment used to ensure that persons with severe mental illness (MI) and mental retardation (MR) are identified and placed in the most appropriate settings to meet their needs. A PASRR screening is needed on all patients discharging to a Medicaid certified nursing facility regardless of payer. The Omnibus Reconciliation Act of 1987 (OBRA) Federal Regulation – 42CFR 483.100 – 483.138
Preadmission Screening and Residential Review (PASRR) (Cont’d) Screening tools: Level I Screening: Identification of possible diagnosis of MI and/or MR. Designate screener via individual hospital P&P. Level II Screening: Identification of serious MI and/or MR with placement recommendations. (Insert screener contact information) The Omnibus Reconciliation Act of 1987 (OBRA) Federal Regulation – 42CFR 483.100 – 483.138
PASRR Level II Exemption Categorical Determination of Dementia/Related Disorder: Primary diagnosis of dementia including Alzheimer’s Disease or non-primary diagnosis of dementia with a primary diagnosis that is not a major illness. The Omnibus Reconciliation Act of 1987 (OBRA) Federal Regulation – 42CFR 483.100 – 483.138
PASRR Level II Exemption Exempted Hospital Discharge: This exemption is allowed for individuals that come directly from a hospital to a Nursing Facility with the expectation that they will be discharged within 30 days from admission into the nursing facility. The Omnibus Reconciliation Act of 1987 (OBRA) Federal Regulation – 42CFR 483.100 – 483.138.
PASRR Level II Exemption Advanced Group Determinations: Provisional admission to a nursing facility: Pending further assessment of delirium where an accurate dx cannot be made until delirium clears. Not to exceed 7 days. Pending further assessment in emergency situations requiring protective services. Not to exceed 7 days. Brief respite care for in-house caregivers with placement to a nursing facility twice a year. Not to exceed 14 days. The Omnibus Reconciliation Act of 1987 (OBRA) Federal Regulation – 42CFR 483.100 – 483.138
Notification of Hospital Discharge Appeals Rights Medicare beneficiaries (primary, secondary or tertiary) who are hospital inpatients have a statutory right to appeal to their state QIO for an expedited review when a hospital, with physician concurrence, determines that inpatient care is no longer necessary. Section 1154 of the Social Security Act CMS-4105-F
Notification of Appeal Rights (Cont’d) Notice – Important Message from Medicare (IM) Explains discharge appeal rights. Hospitals must issue and explain IM within 2 calendar days of admission, and obtain the signature of beneficiary or representative. Hospitals must provide 2 nd IM (new or copy) within 2 calendar days of the day of discharge but not routinely on the day of discharge. Section 1154 of the Social Security Act CMS-4105-F
Notification of Appeal Rights (Cont’d) Beneficiaries have until midnight of the day of discharge to appeal and be responsible for only coinsurance and deductibles until noon of the day after the QIO notifies the beneficiary of it’s decision. Beneficiaries can still appeal after midnight of the day of discharge but can be charged for any hospital services received after discharge. Section 1154 of the Social Security Act CMS-4105-F
Notification of Appeal Rights (Cont’d) Beneficiary must submit request to the QIO either via telephone or in writing. Beneficiary should not be discharged until QIO review completed with outcome unless beneficiary leaves of own accord. QIO notifies Hospital of appeal/request for review. Section 1154 of the Social Security Act CMS-4105-F
Notification of Appeal Rights (Cont’d) Hospital delivers Detailed Notice of Discharge and HINN 12. Hospital will provide all necessary information to the QIO including medical record, IM, and Detailed Notice. QIO has one calendar day to make a decision after all information is received if request is timely. Two calendar days if request is untimely. Section 1154 of the Social Security Act CMS-4105-F
Notification of Appeal Rights Cont’d After QIO review: QIO agrees with hospital: Beneficiary is responsible for continued stay charges beginning at noon of the day after QIO notification to the beneficiary. QIO agrees with beneficiary: No liability to beneficiary except for coinsurance and deductibles. Will need new 2 nd notice and discharge order from physician. Section 1154 of the Social Security Act CMS-4105-F
Notification of Appeal Rights Exceptions Inpatient Acute to Acute transfers: Only 1 st IM needed. Outpatient or Observation: No IM needed. Admissions for non-covered or not reasonable and necessary services: No IM needed. When no Part A days left: IM needed pending days left. Section 1154 of the Social Security Act CMS-4105-F
Hospital Specific Notification & Appeals Process (Insert hospital process)
Ombudsman “An ombudsman is an individual who assists Medicare enrollees in resolving problems they may have with their MCO/PHP. An ombudsman is a neutral party who works with the enrollee, the MCO/PHP, and the provider (as appropriate) to resolve individual enrollee problems.” www.cms.gov/glossary
Ombudsman (Cont’d) “An advocate (supporter) who works to solve problems between residents and nursing homes, as well as assisted living facilities. Also called "Long-term Care Ombudsman”.” www.cms.gov/glossary
Delays, LOS, and Denials: How it all fits together
Avoidable Days = Delays Avoidable days are unnecessary hospitalization days. 3 types of avoidable days: Physician related Department related Continuum related
Avoidable Days = Delays Discharge planning delays lead to extended length of stay. Strategies to avoid discharge planning delays: -Proactive discharge planning (Insert own hospital strategies - add additional slides as needed).
Length of Stay (LOS) Definition of LOS The number of accumulated inpatient days for a patient from admission to eventual discharge. Importance of Managing LOS National comparison to CMS GMLOS Throughput CMS Discharge Appeals Notice compliance Increased risk of further complications and infections Financial benefits and risks
Length of Stay (LOS) (Cont’d) Strategies for LOS management Proactive discharge planning Estimate LOS per case – each patient is unique. (Insert individual hospital processes)
Denials Denials = no payment from or repayment to insurance companies. Process flow: Delays related to discharge planning ↓ Extended length of stay ↓ Denials ↓ Financial risk to hospitals
Proactive Discharge Planning Discharge planning starts on admission - It is imperative that Case Management evaluates and coordinates discharge planning early in the process to provide for a timely discharge from the hospital. Include payers in discharge planning process: Available benefits & co-pays Preferred Providers Pre-Certification and Authorizations Barrier resolution
Pro-Active Case Management An Integral Part of the Interdisciplinary Discharge Planning Team
Identification of Needs Hospital must identify all patients who are likely to suffer adverse health consequences upon discharge if there is not adequate discharge planning. Federal Regulations - Sec 482.43 Conditions of Participation
Identification of Needs (Cont’d) All patients are entitled to a discharge plan. Upon admission, case managers should screen all patients for high risk factors. Age Diagnosis Financial Social History Living arrangements Mental Status Readmission Abuse/Neglect Substance Abuse
Identification of Needs (Cont’d) Daily interdisciplinary discharge planning meetings/huddles provide an opportunity to further identify patients for evaluation. Attendees should include nursing, therapy, case management, and other disciplines as needed.
Identification of Needs (Insert individual hospital process)
Discharge Planning Evaluation Case managers must complete an evaluation on all patients identified as needing discharge planning either through screening or request. Federal Regulations - Sec 482.43 Conditions of Participation
Discharge Planning Evaluation (Cont’d) Evaluation needs to include a comprehensive assessment of: The need for post-hospital services including the most appropriate level of care, i.e., home, home care, placement options. Federal Regulations - Sec 482.43 Conditions of Participation
Discharge Planning Evaluation (Cont’d) The patient’s capacity for self-care and whether he/she can return to their previous setting: Evaluate the prior and current level of functioning. Decision-making capacity Mental Status Home environment Family support system Barriers The availability of services Requires an additional assessment of resources available to the patient. Federal Regulations - Sec 482.43 Conditions of Participation
Discharge Planning Evaluation (Cont’d) Evaluations must be timely so that appropriate arrangements can be made. Case managers must: Work with MDs, RNs, and ancillary departments. Federal Regulations - Sec 482.43 Conditions of Participation
Discharge Planning Evaluation (Cont’d) Discuss evaluation results with the patient and/or representative. In the event the patient and/or representative disagrees with the evaluation/recommendations or is slow in making a decision regarding the recommendations, utilize patient/family conferences to assist in goal setting with expected outcomes. Case Management will arrange for the conference including date, time, location, participants, and documentation of actions. The conference should include patient (if able), family, physician, nursing, case management, social work, and other disciplines as needed, i.e., respiratory, therapy, etc.
Discharge Planning Evaluation (Cont’d) Communicate possible date of discharge. Document evaluation in the patient’s medical record for use in establishing an appropriate discharge plan. Monitor ongoing documentation of status changes and disposition.
Discharge Planning Evaluation Resource Assessment Once the evaluation of needs is complete, the case manager must identify resources available to the patient. Includes: Human resources: Availability of a caregiver, i.e., family and friends Community-based resources Financial resources
Discharge Planning Evaluation Community–Based Resources Home Health Care (HHC) Private Duty Hospice Care Durable Medical Equipment (DME) Acute Care Hospital Transfers Acute Rehabilitation Hospitals Long Term Acute Care Hospitals (LTACHS) Skilled Nursing Facilities (SNF) Extended care placement (ECF custodial) Assisted living Facilities (ALF) Outpatients services (Ex: Rehab, IV Therapy, Dialysis) Other Community resources Transportation
Home Health Care (HHC) “Limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language pathology services, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services provided in the home.” www.cms.gov/glossary
HHC - Skilled Care Skilled Care requirements : Physician ordered A patient must be homebound except for medical appointments and errands, have an able and willing caregiver, be safe in the home environment, and require skilled care.
HHC - Skilled Care (Cont’d) Services provided : Nursing Personal Care Therapies Wound/Infusion Care
HHC - Skilled Care (Cont’d) Insurance coverage Medicare Part A covers at 100%, must be recertified every 60 days. In lieu of Part A, Part B covers as well. Limited Medicaid coverage per state guidelines. Most Medicare replacements and insurances provide coverage pending deductibles, co-pays and duration limits. Long Term Care Policy
HHC - Private Duty No Skilled Services Needed: Patients and families can pay for private duty home care if custodial services are needed. (A minimum of 3 hours and up to 24 hours per day). CNA: Can provide hands on care Companion Services: No hands on care allowed Transportation Housekeeping
HHC - Private Duty (Cont’d) Alternative Payment Options : Long term care policy. State funding – waiver programs. Indigent services available in some areas.
Hospice Care “Hospice neither prolongs nor hastens death.” National Hospice and Palliative Care Organization www.nhpco.org
Hospice Care Team oriented holistic approach to address a person's physical, emotional, and spiritual well- being at the end-of-life. Hospice services are provided for end-stage diagnoses of six months or less. Patient who can no longer benefit from aggressive medical treatment. Physician must provide an order. Medicare, Medicaid, and most insurances cover Hospice Services. National Hospice and Palliative Care Organization www.nhpco.org
Hospice Programs The Hospice team is made up of physicians, nursing, social worker/counselors, and chaplain. Services provided include: Pain and symptom management Counseling for both patient and their loved ones. Support and education to children coping with loss of loved ones. Bereavement support for families after an unexpected or impending death.
Durable Medical Equipment (DME) “Medical equipment that is ordered by a doctor for use in the home. These items must be reusable, such as walkers, wheelchairs, or hospital beds.” Medicare Part A & B covers the costs of DME. Most insurances will also cover DME if deemed medically necessary. www.cms.gov/glossary
Acute Care Hospital to Hospital Transfers For services that cannot be provided in the current hospital setting or patient/family request. A physician must request the transfer and obtain an accepting physician at the hospital. For Medicare Managed Care, Managed Care and other Insurance, follow up with payer for authorization to transfer.
Acute Care Hospital to Hospital Transfers (Cont’d) Contact potential accepting hospital for final acceptance, bed assignment and nurse report. Complete Consent to Transfer forms as needed. Send a copy of all relevant medical records including consent to transfer forms with patient to accepting hospital.
Acute Rehabilitation Hospital Transfers A hospital level of care for aggressive rehabilitation which can be within a system or free standing facility. Meets 75% rule. The patient must be able to tolerate three hours of therapy per day. For Medicare and insurance authorization and payment must meet specific criteria/need for intensive level of rehabilitation.
Long Term Acute Care Hospital Transfers LTACHs provide inpatient care for medically complex patients who need continued hospital stay for up to twenty five days. Limited availability of facilities. Medicare and most insurances will cover when appropriate. Examples: Vent care, high tech IVs, bariatric services, extensive wound care.
Nursing Facility Placements Skilled Nursing & Custodial Care Skilled Nursing Facility: “A facility (which meets specific regulatory certification requirements) which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.” Custodial Care Facility: “A facility, which provides room, board, and other personal assistance services, generally on a long-term basis and which does not include a medical component.” www.cms.gov/glossary.
Skilled versus Custodial Care Skilled care Managed in a SNF Therapy involved Nursing care must be done by a licensed professional Ongoing physician certification needed Covered by insurance for limited time period Custodial Care Managed in a Nursing Home Care can be provided by nurse’s aide Care needed for ADL’s (bathing, feeding, etc.) Only covered by Medicaid, private pay or possible long term care insurance
Skilled versus Custodial Care Medicare guidelines provides skilled care up to 100 days. 1- 20 100% covered. 21- 100 $124.00 a day copay. Once a patient converts to custodial care, they must be free of skilled care for 60 days to have the 100 days available again. Medicare HMO and insurance plans have specific requirements based on type of plan. Insurances do not cover bed holds. Patients and/or families may private pay to hold a nursing home bed upon admission to a hospital. Medicaid bed holds in nursing homes are based on SNF census and government reimbursement to keep the bed open. www.cms.gov Medicare Part A
Assisted Living Facilities “A type of living arrangement in which personal care services such as meals, housekeeping, transportation, and assistance with activities of daily living are available as needed to people who still live on their own in a residential facility. In most cases, the "assisted living" residents pay a regular monthly rent. Then, they typically pay additional fees for the services they get.” ALFs are custodial care and not all provide 24-hour nursing care. Some ALFs have “extended care licenses” that allow them to do more nursing care without needing a nursing home. HHC can follow patients at ALFs. www.cms.gov/glossary
Outpatient Care Patients that need follow up care, but do not qualify for any of the other levels of care previously discussed or choose to attend an outpatient program. Ambulatory Settings Infusion therapy Wound care Rehabilitation services Dialysis
Dialysis Patients Key areas to remember: Medicare typically takes 3 months to approve. Federal government typically does not cover ongoing dialysis for illegal immigrants. Options of Peritoneal vs. Hemodialysis. Transportation to and from dialysis treatment. Schedule of treatment days. Strain on patients emotionally, physically financially, work, family, etc.
Other Community Resources Area Agency on Aging Meals on Wheels Diagnosis related organizations i.e. American Cancer Society Mental Health Providers Public Health Departments Public Transport Services State Department of Children and Family Services
Transportation All patients must be assessed for the most appropriate mode of transportation needed: Private Auto Taxi Cab Wheelchair Transport Medichair Transport Ambulance – BLS, ALS Air Ambulance
Discharge Planning Evaluation Financial Resources Once the level of care needs are identified, there must be an assessment of the patient’s insurance benefits or ability to pay for services required to provide a safe discharge. 3 types of financial categories: Funded patients Under funded patients Unfunded patients
Funded Patients Patients that have some type of insurance for the possible coverage of services post discharge. Types of insurances include Medicare, Medicaid, Managed Care, Worker’s Compensation, Auto insurance, COBRA insurance, and Long Term Care Policies. Insurances must be contacted for benefit information and authorization if necessary.
Under Funded Patients Patients that have insurance but may lack the benefits/coverage to adequately pay for post acute care services. -No HHC, SNF benefits -Inability to pay deductibles or co-pays May not qualify for any Federal or state assistance. Determine if patient and/or family can pay out-of-pocket for services. Determine if any governmental, community or hospital- based financial assistance is available on a case by case basis. Use cost-benefit analysis methodology as needed.
Unfunded Patients Patients that lack any insurance to cover post discharge services. Includes undocumented immigrants. Determine if patient and/or family can pay out- of-pocket for services. Determine if patient will qualify for any Federal, state, community or hospital-based financial assistance. Use cost-benefit analysis methodology as needed.
Cost-Benefit Analysis A method of analyzing two or more alternatives that meet the appropriate level of care needs to determine which delivers the best return on the original investment. Used to gain support from hospital administration to pay for post acute care services. Average daily cost (ADC) of remaining in the hospital for a specified timeframe versus the cost of the post acute care services. Return on investment: Days saved multiplied by the ADC minus the total costs of post acute care services = Cost savings.
Cost-Benefit Analysis Example Mrs. Doe an unfunded patient, 30 years old was admitted with cellulitis of her bilateral extremities. She has had an uneventful hospital stay of 3 days and is ready for discharge but requires IVABX 2 x per day for 5 more days. Question: Should Mrs. Doe remain in the hospital to finish the course of IVs or can she discharge home with post acute care services for the completion of the IVs? Her average hospital cost is $1000.00 per day. The hospital has an outpatient department where she can receive her IVABX at a cost of $100 per visit. She will need 2 visits per day. The hospital also provides free transportation to and from the hospital from 7:00 am until 8:00 pm.
Cost-Benefit Analysis Example (Cont’d) Cost-Benefit Analysis: 5 more inpatient days in hospital ($1000 x 5 days) = $5,000.00 Outpatient care twice a day times 5 days = $200.00/d x 5 days =$1,000.00 Transportation = free service to patient $5000 - $1000 = $4000 cost savings
Discharge Plan RN, SW or other qualified professional must develop or supervise the development of a discharge plan if the evaluation indicates a need for such plan. Federal Regulations - Sec 482.43 Conditions of Participation
Discharge Plan (Cont’d) Case managers must: Arrange for the initial implementation of the plan. Reassess if conditions change. As needed, must counsel the patient and/or representative to prepare them for discharge. Document all interventions and the patient’s consent to the plan in the medical record. Federal Regulations - Sec 482.43 Conditions of Participation
Discharge Plan (Cont’d) Case managers must: Provide a list of Home Health Agencies or Skilled Nursing Facilities that are available to the patient, participating in the insurance plan, and in the geographic area where the patient resides or requests. Document in the patient’s medical record that the list was provided. Federal Regulations - Sec 482.43 Conditions of Participation
Discharge Plan (Cont’d) Case managers must: Inform the patient or representative of their freedom to choose among participating Medicare providers and, when possible, respect their preferences when they are expressed. Not specify or otherwise limit the qualified providers that are available to patient. Identify any HHCA or SNF to which the patient is referred in which the hospital has a disclosable financial interest. Must be included in the discharge plan. Federal Regulations - Sec 482.43 Conditions of Participation
Discharge Plan (Cont’d) (Insert hospital process or forms)
Transfer or Referral The hospital must transfer or refer patients along with necessary medical information to appropriate facilities as needed for follow-up or ancillary care. Federal Regulations - Sec 482.43 Conditions of Participation
Transfer or Referral (Cont’d) Provide from Medical Record: Patient status Demographic – Insurance info Transfer Forms Physician notes/plan of care Medication Records Therapies Labs and Imaging Advance Directives All other documentation based on hospital policy or requested by the post acute care agency/facility. Federal Regulations - Sec 482.43 Conditions of Participation
Transfer or Referral (Insert hospital process)
Reassessment The hospital and Case Management must reassess it’s discharge planning process on an on-going basis. The department’s reassessment must include a review of discharge plans to ensure that they are responsive to discharge needs. Federal Regulations - Sec 482.43 Conditions of Participation
Barriers to Discharge Planning Sometimes, it’s like pulling a rabbit out of your hat!
Common Barriers Acuity Age Bariatric Issues Bed Availability Behavior/Restraints Finances Patient/Family Physicians Lack of Resources
Common Barriers (Cont’d) Advanced Directives/DNR paperwork Abuse and Neglect Homeless Legal Transportation Undocumented Immigrants Incompetency Issues - Guardianship
Review Questions 1.True or False: Discharge Planning is a process used to decide what a physician needs for a smooth move from one level of care to another. 2.True or False: Discharge planning begins when the discharge date is known. 3.True or False: Establishing a safe discharge plan is a foundation of discharge planning. 4.Patient is admitted as an observation on 12/1, converted to inpatient on 12/2. What date can they be discharged to a Skilled Nursing Facility under Medicare coverage?
Review Questions 1.What does the acronym PASRR stand for? 2.Name one type of avoidable day. 3.Length of stay is the number of accumulated ______ days for a patient from admission to eventual discharge. a.Observation b.Inpatient c.All of the above
Review Questions 1.A case manager must arrange for the _____ implementation of the discharge plan. a.Whole b.Partial c.Initial 2.True or False: A Medicare patient does not have the freedom to choose a specific HHC agency or SNF for post discharge care. 3.List two common barriers to discharge planning.
Answer Key 1.False 2.False 3.True 4.12/5 5.Preadmission Screening and Residential Review 6.Physician, Department or Continuum 7.Inpatient 8.Initial 9.False 10.See barrier list
References & Resources Balanced Budget Act of 1997 Centers for Medicare and Medicaid Services (CMS) –www.cms.gov –Glossary –CMS – 4105F Federal Regulations –Sec 482.43, Hospital Conditions of Participation –Sec 10116, 10118-19 –42 CFR 483.100- 483.138 –42 CFR 411,424 –42 CRR 417.23 (b)2 National Hospice & Palliative Care Organization –www.nhpco.org Social Security Act – sections 1154, 1861, 1867, 1877, 1986 –www.ssa.gov The Omnibus Reconciliation Act of 1987 (OBRA)