Hospital Patient Safety Initiatives: Discharge Planning Michele Kala, RN

October 2011-Developed by CMS Related to three Conditions of Participation (CoPs) 482.21 Quality Assessment and Performance Improvement (HFAP Hospital Chapter 12) 482.42 Infection Control (HFAP Hospital Chapter 7) 482.43 Discharge Planning (HFAP Hospital Chapter 15) Currently being used in acute care hospital only—Not critical access hospitals.

Worksheet Purpose Reduce hospital acquired conditions (HAC) including hospital acquired infections (HAI) and preventable readmissions. Designed to assist surveyors and hospital staff to identify when and where compliance is an issue.

CMS Worksheet Development Was in draft form until midyear 2013 Currently in use by state surveyors and accrediting agencies.

CMS Worksheets: Facilitate recording of observations by surveyors Are a self-assessment tool

Findings Hospitals with higher readmission rates may be at greater risk for noncompliance with all three CoPs. The tools assist facilities in focusing on key issues that impact positive patient outcomes and thereby compliance.

Verification Methods Interview Observation Topic Specific Document Review Medical Record Review Other Document Review

Hospital Patient Safety Initiatives Quality Assessment and Performance Improvement Infection Control Discharge Planning

Discharge Planning Worksheet Four Sections 1. Facility Information (Demographics) 2. Policies and Procedures 3. Reassessment and QAPI 4. Discharge Planning Tracers

2. Policies and Procedures Are discharge planning policies and procedures in place for all inpatients? Verification: Are discharge planning activities apparent on all nursing units visited? Are the staff members assigned to discharge planning following the facility policies regarding the process? 2.1 Are discharge planning policies and procedures in effect for all inpatients? Specifically:

2. Policies and Procedures, cont. Does discharge planning apply to any outpatients? Do all inpatients get a discharge assessment and plan? If not, is a process in place for reassessment and development of a plan if warranted? Same day surgery, ED patients, observation patients?? 2.2 Does the discharge planning process apply to certain categories of outpatients? 2.3 Is a discharge plan prepared for each inpatient?

2. Policies and Procedures, cont. For patients not initially identified as in need of a discharge plan, is there a process for updating this determination based on changes in the patient’s condition or circumstances? Verification: Does the discharging planning policy address the changes in patient condition that would result in the initiation of a discharge plan? 2.4 For patients not initially identified as in need of a discharge plan, is there a process for updating this determination based on changes in the patient’s condition or circumstances? Specifically,

2. Policies and Procedures, cont. Do inpatient staff know how, when and whom to notify to initiate the process based on change in patient status?

2. Policies and Procedures, cont. Is there a process for patients, or their representatives, and physicians to request a discharge planning evaluation? Verification How are patients notified of the right to have a discharge planning evaluation upon request? 2.5 Is there a process for patients, or their representatives, and physicians to request a discharge planning evaluation?

2. Policies and Procedures, cont. How are the medical staff notified they may request a discharge planning evaluation? Can both the discharge planning staff and the nursing staff describe the process for patient requests for a discharge evaluation?

2. Policies and Procedures, cont. Patients, their representatives and members of the medical staff will be interviewed to determine if they are aware they can request a discharge planning evaluation. If either group state they were not aware, the facility must provide verification that notification had been made.

2. Policies and Procedures, cont. Does the hospital discharge planning policy address reassessment of the plan based on changes in patient condition, available support or post hospital care requirements?

3. Discharge Planning-Reassessment and QAPI Is the discharge planning process examined through QAPI—are indicators of performance in place that are reported routinely to the QAPI committee? Are readmissions tracked as a part of the quality process

3. Discharge Planning-Reassessment and QAPI, cont. Are readmissions classified as avoidable? Can avoidable admissions be attributed to the discharge planning process, and if yes, has the process been changed to address the problems?

3. Discharge Planning-Reassessment and QAPI, cont. Does the hospital have a mechanism for collecting data from post-discharge providers regarding the effectiveness of the discharge planning process? (long term care, home health and hospice, community based outpatient providers, etc)

4. Discharge Planning Tracers The surveyors will conduct tracers on current inpatients and discharged patient medical records. They will be looking for patients discharged to other care facilities and patients discharged home with specialized care and/or community based assistance following discharge.

4. Discharge Planning Tracers Tracers can be conducted many different ways: Facility completion of the tracer forms with review by the surveyor and additional chart review by the surveyor for verification. Surveyor completion of all chart reviews. A group of discharge planning staff, each with a discharge chart selected by the surveyor, review the files for completeness as a group with surveyor oversight.

4. Discharge Planning Tracers The following criteria is evaluated in each chart reviewed: Was a discharge screening done and when? Was the screening process correctly applied per facility policy?

4. Discharge Planning Tracers If the assessment failed to demonstrate the need for an evaluation, were the patient and the patient’s physician made aware they could request an evaluation? Did staff defined by hospital policy conduct the evaluation and develop the discharge plan?

4. Discharge Planning Tracers Is the evaluation documented in the patient’s medical record? Did the evaluation include an assessment of the patient’s post discharge care needs being met in the environment from which he/she entered the hospital?

4. Discharge Planning Tracers FOR PATIENTS ADMITTED FROM HOME: Did the evaluation include an assessment of– patient’s ability to perform activities of daily living? the patient or family’s ability to provide self care/care?

4. Discharge Planning Tracers FOR PATIENTS ADMITTED FROM HOME, cont: Did the evaluation include an assessment of– whether specialized medical equipment or home modification will be required? whether the required equipment is available and/or the home modifications can be made safely?

4. Discharge Planning Tracers FOR PATIENTS ADMITTED FROM HOME, cont: Did the evaluation include an assessment of– Available community based services if the patient and/or family would not be able to meet the patient’s needs? If the assessment determined the patient would require SNF or Home Health Care, were geographically appropriate lists of providers given to the patient?

4. Discharge Planning Tracers FOR PATIENTS ADMITTED FROM LONG TERM CARE: Did the evaluation include an assessment of– Whether the previous facility is capable of managing the current discharge needs of the patient. Whether the patient’s insurance coverage would provide for necessary services.

4. Discharge Planning Tracers FOR PATIENTS ADMITTED FROM LONG TERM CARE, cont: Was the assessment timely to avoid delays at discharge? Was the patient or family involved in discussion of the results of the evaluation?

4. Discharge Planning Tracers FOR PATIENTS ADMITTED FROM LONG TERM CARE, cont: Did the discharge plan match the identified needs? If significant changes in patient condition occurred after the plan was developed that changed discharge needs, was the plan adjusted accordingly?

4. Discharge Planning Tracers For patients discharged home, Were the patient and family provided training regarding home care? Were legible, non-technical discharge instructions provided? Was a medication reconciliation provided at discharge? 4.18 For patients discharged to home, did the hospital arrange for the initial implementation of the discharge plan? Specifically, look for evidence of the following, if applicable, based on the discharge plan: teach back, repeat back, etc.

4. Discharge Planning Tracers For patients discharged home, cont. Was evidence of education on admission vs. discharge medication provided, highlighting changes? Were appointments made for referrals to established or new PCPs?

4. Discharge Planning Tracers For patients discharged home, cont. Were referrals for specialized home services and community based services initiated prior to discharge? Was required DME arranged for delivery? Were the discharge instructions transmitted to the post discharge provider?

4. Discharge Planning Tracers For patients discharged to a post-acute care setting other than home: Was necessary medical information ready at time of transfer and sent to the receiving facility? Was there a delay in discharge due to lack of timely implementation of the plan?

4. Discharge Planning Tracers For patients discharged to a post-acute care setting other than home, cont: Identify the services initiated during the hospital stay, per the list provided.(4.21)

4. Discharge Planning Tracers For all discharge records: Is there documentation in record of the provision of the results of testing pending at the time of discharge to the patient or physician? Was the chart reviewed for readmission within 30 days?

ADDITIONAL RESOURCES www.beckershopitalreview.com: 10 Medical Conditions With the Highest Readmission Rates, May 8, 2013 Reducing Hospital Readmissions Rates: How to Avoid Upcoming Penalties and Maintain Patient Wellness, December 17, 2013 5 Steps for Reducing Inappropriate Hospital Readmissions, November 1, 2013

ADDITIONAL RESOURCES www.commonwealthfund.org - Reducing Hospital Readmissions: Lessons from Top-Performing Hospital, April 2011 www.avoidreadmissions.com –Dedicated to providing access to articles on reducing readmission rates.

Please submit questions to: info@hfap.org