Transcript Federal Register - Arkansas Hospital Association

CMS HOSPITAL CONDITIONS OF
PARTICIPATION (COPS) 2011
What PPS Hospitals Need to Know
About the UR and Discharge Planning Standards
Speaker
Sue Dill Calloway RN, Esq.
CPHRM
AD, BA, BSN, MSN, JD
President
Patient Safety and Healthcare
Education
5447 Fawnbrook Lane
Dublin, Ohio 43017
614791-1468
[email protected]
2
The Conditions of Participation
 Regulations first published in 1966
 Many revisions since with final interpretive guidelines June 5, 2009
(Tag 450 Medical Record) and anesthesia (December 11, 2009,
February 5, 2010, May 21, 2010 and February 14, 2011) and
Respiratory and Rehab Orders August 16, 2010 and Visitation 2011
 Published in the Federal Register first (42 CFR
Part 482) 1
 CMS then publishes Interpretive Guidelines and
some have survey procedures 2
 Hospitals should check this website once a month for
changes
1www.gpoaccess.gov/fr/index.html
2www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp
3
4
Respiratory and Rehab Orders
 Published in the August 16, 2010 Federal Register
 Allows a qualified licensed practitioner who is
responsible for the care of the patient (such as a
PA or NP)
 Who is acting within their scope of practice under
state law
 Can order respiratory or rehab order (physical
therapy, occupational therapy, speech)
 Must be privileged (authorized) by the MS
 Must have hospital P&P to allow also
5
Visitation
 Effective January 19, 2011
 Must rewrite policy on visitation including visiting
hours in ICU
 Must inform each patient of their visitation rights
 Must include any restrictions on those rights
 Can not restrict or deny visitation privileges on the
basis of race, color, national origin, religion, sex,
sexual orientation, gender identity or disability
 For example same sex partner may present
visitation advance directive
6
Federal Register Visitation Changes
7
TJC Revised Requirements
 TJC (The Joint Commission) issues 27 pages of
changes effective July 20091
 Reflects their standards as being in compliance with the
CMS CoP
 Standards are for hospitals that use them to get deemed
status and payment for M/M patients
 So now TJC standards closer to the CMD CoPs (not
called JCAHO any more)
 Scored after July 1, 2009 and continued in 2011
1www.jointcommission.org/Library/WhatsNew/Hospital_deeming%20application_January_%20200
9_Update.htm
8
TJC Standard Changes
 LD.04.01.01 Hospital is required to have a UR plan
 Added 2 EPs (Elements of Performance) 17 and 18
 Must also have a UR committee which consists of at
least two members who are physicians
 The committee is responsible for reviewing the
medical necessity of admissions, LOS, and services
for M&M patients
 Revisions made to comply with the CMS CoPs
 Also made a change to LD.04.01.05 published
January 12, 2011
9
TJC Standard Changes
 LD.04.01.05 The hospital manages its programs
effectively
 For psychiatric hospitals that use accreditation for
deemed status purposes:
 The hospital has a director of social work services
who monitors and evaluates the social work
services furnished
 Note: Social work services are furnished in
accordance with accepted standards of practice
and established P&P
10
Mandatory Compliance
 Hospitals that participate in Medicare or Medicaid
must meet the COPs for all patients in the facilities
 Not just those patients who are Medicare or
Medicaid
 Hospitals accredited by TJC, AOA, or DNV
Healthcare have what is called deemed status
 This means you can get reimbursed without going
through a state agency survey
 Can still get complaint or validation survey
11
CMS Hospital CoPs
 All Interpretative guidelines under state operations
manual are found at this website1
 Appendix A, Tag A-0001 to A-1163 and 370 pages long
 Interpretative guidelines updated February 14, 2011 for
fourth time
 Manuals
 Manuals are now being updated more frequently
 Still need to check survey and certification website once
a month and transmittals 2
1http://www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf
2 http://www.cms.gov/Transmittals/01_overview.asp
12
13
14
CMS CoP
 The Utilization Review section (abbreviated UR)
starts at tag 652
 Has not been updated in long time
 TJC amended the leadership chapter (LD.04.01.01) to
require a UR plan and UR committee with at least two
physician members and in effect in 2011
 Added 2 EPs to comply with the MIPPA or Medicare
Improvements for Patient and Providers Act
 The Discharge Planning session starts at tag 800
 Watch for changes in the future in discharge planning in light of
the concern for preventing unnecessary readmissions
15
Utilization Review
 Important in healthcare for many reasons
 Making sure quality care is provided
 In most cost effective manner
 To reduce hospital admissions and length of stays
 Want to make sure care is medically necessary especially
in light of the RACs or recovery audit contractors
 Hospital should make sure has good UR plan and
UR staff
 So what’s in your UR plan and in your UR program??
 Should update it on an annual basis
16
Utilization Review Plan
17
Utilization Review Critical Access Hospitals
 Currently Medicare reimbursement for CAHs is not
based on DRG designation so not subject to
mandatory reviews
 No similar UR section in the CAH manual for Medicare
patients
 However, Rural Healthcare Quality Network (RHQN)
recommends hospitals conduct internal reviews using the
InterQual criteria if possible (many private insurers use)
 Recommend this even though other criteria sets are
available and less costly
 Notes that in the future mandatory reviews may become
a reality
18
Utilization Review
 Certification (justification) may be required for
certain procedures or a hospital stay before an
insurance company will pay for the stay
– LOS usually assigned by physician or nurse reviewer,
hospital committee, insurance provider or a combination
of the four
 Medicare reviewers currently use InterQual criteria
when reviewing medical records to establish if
inpatient admissions were medically necessary
 InterQual (or Milliman-USA) criteria are used by case
managers when conducting inpatient utilization review
19
Utilization Review
 InterQual criteria are clinically based on best practice,
clinical data and medical literature
 The criteria are updated continually and released
annually
 The criteria is the first level screening tool to assist in
determining if the proposed services are clinically
indicated and in the appropriate setting
 Can’t be use to deny a case as only physicians determine
clinical appropriateness
 If does not meet then case is referred to a physician
reviewer for further determination of medical necessity
20
Utilization Review
 Hospital and the attending physician will have the
opportunity to provide additional information on the
inpatient Medicare patient that may not have been
available to the physician reviewer
 Of course, case may still be denied and there will be
opportunity to request a review by a different
physician reviewer
 If second physician reviewer denies it then
opportunity to have case reviewed by an
administrative law judge (ALJ)
 If denied, Medicare takes money back for payment of
the hospital stay
21
QIO Role in UR
 This is why it is important for hospitals to respond back
to notices in a timely manner
 This is the amount of time indicated on the letters
received from the Quality Improvement Organizations or
QIOs
 The QIO does the peer review activity for CMS
 Every state has a QIO under contract by CMS
 QIO is involved with the Scope of Work (SOW) which is
updated every 3 years
 9th SOW started August 2008 thru July 31, 2011 and 14 states worked
on care transition project (See MedQic)
22
Medicare Quality Improvement Org Program
 The Medicare QIO program was created by law in
1982 to improve quality and efficiency of services to
Medicare patients
 First phase in the early nineties did this through
peer review (PRO) to identify cases where
professional standards were not met for initiating
corrective actions
 In second phase, had significant changes with how
to improve care and promotion of public reporting
and development of scope of work projects
23
CMS and Quality of Care
 IOM March 2006 report recommended changes and
CMS makes improvements as result of the MMA
Law
 Medicare Prescription Drug, Improvement, and
Modernation Act of 2003, section 109(d)(1)
 CMS views QIO program as the cornerstone to
improve quality and efficiency for Medicare patients
 CMS undertaking activities to manage and measure
quality and they want value based purchasing and
has a roadmap
 More under discharge planning
24
CMS Roadmap for Quality Measurement
25
9th Scope of Work SOW
 Many times surveyor will ask to see if the hospital
has signed a contract with their QIO to participate in
the SOW
 Many times if this is done CMS surveyor may not
scrutinize the UR standards
 14 states worked on the Care Transition Project to promote
seamless transition across settings including hospital to home
and to prevent readmissions
 Ten focus areas; heart failure, MRSA, pressure ulcers, R&S,
AHRQ culture tool, surgical care, drug safety, public reporting,
LD and quality assessment tool
 Focused disparities (diabetes) and chronic kidney disease
26
9th Scope of Work SOW
 QIOs will continue to review quality of care given to
Medicare patients, beneficiary appeals of certain
notices, potential EMTALA, and implementing QI
activities as a result of case reviews, sanctions etc
 Some states adopted some of the initiatives
 Some measures overlap with IHI (Institute for
Healthcare Improvement) 5 Million Lives Campaign
and 100K live campaign
 Some also overlap with American Heart Association
on the Get with the Guidelines campaign (GWTG)
27
Medical Necessity
 CMS takes the position that whether a patient
should be admitted as an inpatient is a complex
medical judgment that should be made by the
physician based on;
 Severity of the “signs and symptoms” exhibited by
the patient,
 Medical probability of an adverse outcome for the
patient, and
 The need and availability of diagnostic studies
 See MLN Matter SE1037
28
Transmittal SE1037 1/25/2011
29
www.cms.gov/manuals/downloads/pim83c06.pdf
30
www.cms.gov/manuals/Downloads/bp102c01.pd
f
31
Inpatient Review for Medicare Patients
 A tool used by the QIO may be helpful to determine
medical necessity but does not guarantee payments
for admission or continued stay
 Demographics
 Patient name, ID number
 Attending Name and contact information
 The day or dates under review
 SI (symptom intensity) How sick is the patient? This
places the patient’s services in context with their clinical
condition and is needed both for the initial review and
for concurrent review
32
Medical Necessity
 Symptom intensity (continued)
 What is the main clinical issue?
 Abnormal vital signs?
 Pain present- where, what is the cause?
 Neurological status: alert to obtunded
 Brief description of diagnostic tests (especially if lab
or x-rays are abnormal)
 Any consultations and evaluations or procedures?
33
Intensity of Services
 IS (Intensity of services) What care is the patient
receiving?
 IV medications and frequency
 Any IV PRN meds given for nausea, pain? How
often each day?
 IV Fluids/ TPN
 Blood or blood products (should have a HCT as a
reason)
 Oxygen needed? FiO2 and route? ABGs done or
O2 sats?
34
Discharge Screens
 DS (Discharge Screens) What is the long-term
plan? An “unsafe” discharge will initiate a quality of
care review.
 What is the expected destination after
hospitalization?
 What discharge planning activities are being done
 What care needs are there post discharge?
Educational Needs?
 Are there any significant psychosocial issues?
35
Intensity of Services
 Intensity of Services continued
 Diet/Tube feeds/gavage (what is infants weight)
 If patient is on a sliding scale, What were the
high/low glucose values? How many coverage
units were given on each day (not the routine
doses)?
 Wound management: describe wound and
dressing/debridement/special issues
 Any other treatments or therapies?
36
CMS 9th Scope of Work Projects
37
38
MedQIC
 MedQIC has the quality net website with free
resources for QI interventions, tools, and toolkits
 http://www.qualitynet.org/dcs/ContentServer?pagen
ame=Medqic/MQPage/Homepage
 Sign up to get their free monthly publication called
MedQiC (Medicare Quality Improvement
Community)
 Purpose is to share resources including resources
on the 9th scope of work, delirium, depression,
infections, incontinence, restraint, UTI, patient
safety, transitions in care, AV fistula first, etc.
39
40
CMS Guidance on Hospital Inpatient Admissions
 Medical necessity is a hot button with the RACs,
Medicare Administrative Contractors (MACs), fiscal
intermediaries (FIs) and comprehensive error rate
testing (CERT) contractors
 CMS released an educational guideline to assist
hospitals regarding inpatient admission decisions
 To help ensure that hospitals are using proper
screening criteria to analyze documentation and
make medical necessity determinations
 Chapter 6 of the Medicare Program Integrity Manual, Section 6.5 is
available at http://www.cms.gov/manuals/downloads/pim83c06.pdf on
the CMS website
41
42
Utilization Review A-0652
 Hospital must have a UR plan that provides for
review of services furnished by the institution and
the members of the MS to Medicare and Medicaid
beneficiaries
 UR plan should state responsibility and authority of
those involved in the UR process
 Surveyor will make sure activities performed as in
UR plan
 Need to include review of medical necessity of
admissions
43
Utilization Review
 Review of medical necessity for:
 Appropriateness of the setting
 Extended stays and
 professional services rendered
 This is really important in light of the Recovery
Audit Contractors or RACs
 American Hospital Association, AHIMA, and CMS has
website of resources for the RACs
 RAC program to identify improper Medicare payments
including overpayment and underpayments
44
AHA Website on RAC Program
http://www.aha.org/aha/issue
s/RAC/index.html
45
CMS RAC Website
http://www.cms
.gov/rac/
46
http://ahima.org/resources/rac.aspx
47
Survey Procedure Tag 652
 These are the questions to the surveyors to verify
 Determine that the hospital has a utilization review plan
for those services furnished by the hospital and its
medical staff to M&M patients.
 Verify through review of records and reports, and
interviews with the UR chairman and/or members that UR
activities are being performed as described in the hospital
UR plan.
 Review the minutes of the UR committee to verify that
they include dates, members in attendance, extended stay
reviews with approval or disapproval noted in a status
report of any actions taken.
48
UR Plan
 UR Plan should say who is on the UR committee
 Such as the physician advisor, CNO, discharge planners,
social services, business office manager, HIM director,
administration, UR nurse, billing office, etc.
 Should discuss meeting frequency such as meets
once a month
 It should address conflicts of interest so anyone
with financial interest in the hospital can not be on
the committee
 Should include a confidentiality section so all data,
minutes, worksheets are confidential
49
Functions of a UR Committee
 Should include functions of the UR committee such
as:
 To establish and carry out a program of admission
certification and continued stay review of all patients
in accordance with applicable state and federal laws
and regulations
 To supervise the utilization review activities of non
physician reviewers
 To assure coordination between concurrent review
activities, quality assurance, and risk management
activities, and reimbursement agencies
50
Functions of the UR Committee
 To assist in the selection and ongoing modification of
criteria and standards
 To recommend changes in hospital procedures, medical
Staff practices or continuing education programs as
indicated on analysis of review findings
 To serve as utilization review committee for the skilled swing
bed activities
 To act on any topics referred to them by the Medical Staff,
Administration, or any other hospital committee
 To address potential over-utilization or under utilization
issues
51
UR Plan
 UR plan can include the method of review
 All patients admitted to the hospital will reviewed by the
UR nurse for appropriateness and medical necessity
 Includes M&M patients, CHAMPUS, patient insurance
covered by private contract, self pay, etc
 What guidelines are used such as InterQual or Milliman
etc.
 Concurrent reviews are done using the same criteria or
the information provided by the insurers
 If criteria does not exist then will work with physician and
patient and family to move the patient to the appropriate
level of service
52
UR Plan
 If UR nurse sees unusually high costs or frequent
ordering of excessive services then can talk to
physician advisor
 Or can subject case to Preadmission Review or indepth peer review
 Decisions made by UR nurse will be based on
standards adopted by the MS and QIO
 Include in the policy the preadmission review process
 Precertification of elective surgeries should be done by
the physician’s office but hospital will verify precert
 Include admission review process
53
Utilization Review
 Make sure you get observation rules correct
especially with condition code 44
 CMS issue UR CoP Memo June 2, 2007
 Exception for UR plan is if the Hospital has an
agreement with the QIO in their state to assume
binding review
 Hospitals may have a contract with QIO to review
admissions, quality, appropriateness and diagnostic
information related to Medicare inpatients
 Surveyor will look to see if hospital has a signed
contract with their state QIO
54
Composition of UR Committee 654
 Consists of 2 or more practitioners who carry
out UR function
 At least 2 members must be doctors
 The UR committee must be either a staff
committee of the hospital or
 A group outside that has been established
by the local medical society for hospitals in
that locale and established in a manner
approved by CMS
55
UR Committee 654
 A committee may not be conducted by an
individual who has a direct financial or
ownership interest (5% or more) or
 Who was professionally involved in the care
of the patient whose case is being reviewed
 Surveyor will look to see if the governing
board has delegated UR function to a outside
group if impracticable to have a staff
committee
56
Frequency of Review 655
 UR plan must provide review for
Medicare/Medicaid (M/M) patients with
respect to medical necessity
 Admissions (before, at, or after admission)
– Usually should screen within one working day of admission and
use severity of illness or intensity of service as discussed
previously
 Duration of stay
 Professional services furnished including drugs
and biologicals
57
Scope of Reviews A-0655
 Reviews may be on a sample basis except for
reviews of cases assumed to outlier cases
because of extended stay cases or high costs
 Surveyor will examine UR plan to determine if
medical necessity is reviewed
 P&P should state what to do such as UR nurse speaks
with attending, goes to the physician reviewer, when
ABNs are issued, IM Notices, QIO guidelines etc.
 If IPPS hospital there should be a review of the
duration of stay in cases assumed to be outlier
58
Admissions or Continued Stay
 Determination that admission or continued
stay is not medically necessary is made by
one member of UR committee if the
physician concurs with determination or fails
to present their views when afforded the
opportunity
 Must be made by two members in all other
cases (656)
59
Admissions or Continued Stay
 Before determination not medically
necessary, UR committee must consult the
MD responsible for the care and afford
opportunity to present their views
 Then committee must provide written
notification no later than two days after
determination to the hospital, patient and
practitioner responsible for care
60
Admissions or Continued Stay
 If attending doctor does not respond or contest the
findings of the committee, the findings are final
 If physician of UR committee finds not medically
necessary no referral of committee is necessary
and he may notify the attending doctor
 If non-physician makes the determination it must
go to the committee or the physician reviewer
 A non-physician can not make this final
determination
61
Extended Stay Reviews A-0657
 This tag number addresses hospitals that are not
paid under the prospective payment system
 UR committee must make periodic review of
inpatients receiving hospital services during an
extended stay (outlier)
 UR committee must conduct a review as specified
in the UR plan
 Surveyors will look at the hospital’s definition of
extended stay in the UR plan
62
Review of Professional Services 658
 The committee must review professional services
provided
 To determine medical necessity
 And to promote the most efficient use of available
health facilities and services
 Topics for the committee may include overuse or
underuse of necessary services
 Timeliness of scheduling of services such as
diagnostic and operating rooms
63
Discharge Planning
 Discharge planning is important in today’s
environment especially in light of reform laws
 If hospital do not do this right and the result is a
higher that average readmission rate in 2012, the
hospital could be financially penalized by CMS
 20% of Medicare patients are readmitted within 30
days
 CMS is expected to make some changes to this
section because of this
 Hospitals need to reengineer the discharge process
64
Patient Protection and Affordable Care Act
 The new law establishes a VBP program, or
value-bases purchasing, to pay hospitals for
their actual performance
 Measures selected for pay include those used
in the Medicare pay for reporting program such
as measures for heart attack, heart failure,
pneumonia, surgical care and patient
satisfaction (HCAHPS)
 Purpose to improve coordination, quality and
efficiency of health care services
65
Patient Protection and Affordable Care Act
 Must develop episode-of-care and post-acute care
quality measures
 Hospitals are required to submit data on these quality
measures through an EHR which will be posted on
hospital compare
 Law specifies the following episode-of-care quality
measures
 Functional status improvement
 Rates of avoidable hospital readmissions
 Rates of discharge to the community
 Rates of admission to an emergency department after a
hospitalization
66
Readmission Rates Vary
 Readmission rates vary widely in the US
 Too often quality of care during transition from hospital to
home is not good
 Data shows readmission rate for MI and CHF vary
 Found only modest association between performance on
discharge measures and patient readmission rates
 Public reporting unlikely to yield large reductions in
unnecessary readmissions
 We need to improve in the ambulatory section
 See A. K. Jha, E. J. Orav, and A. M. Epstein, Preventing
Readmissions with Improved Hospital Discharge Planning,
NEJM Dec 31, 2009 361 (27):2637-2645
67
Readmissions and Discharges
 One in 5 hospital discharges (20%) is complicated
by adverse event within 30 days
 20% were readmitted within 30 days with 1/3 leading to
disability
 Often leads to visits to the ED and rehospitalization
 6% of these patients had preventable adverse
events
 66% were adverse drug events
 The incidence and severity of adverse events affecting patients
after discharge from the hospital. Forster AJ, Murff HJ,
Peterson JF, Gandhi TK, Bates DW. Ann Intern Med.
2003;138:161-167
68
Preventing Readmissions
 76% of readmissions are thought to be preventable
 It is the preventable ones that hospitals need to
work on
 Medicare data shows that over half of patients
readmitted received no follow up care
 Recent studies show interventions targeted at postacute care transition can reduce readmissions by
one third (Coleman and Naylor)
 Technologies for Improving Post-acute Care Transitions,
Center for technology and Aging, Sept 2010
69
Preventing Readmissions
 HHS study finds a high rate of Medicare patient
deaths due to adverse events (AE)
 15,000 Medicare patients experience an AE during
healthcare delivery that lead to their death every
month
 Nov 16, 2010 OIG study
 Found 1 in every 7 discharges (13.5%) experience
an AE and the cost to CMS is $324 million
 44% of all AE were preventable and 51% were not
 November 2010, OEI-06-09-00090
70
71
AHA Guide to Reduce Avoidable Readmissions
 AHA had committees look at the issue of how to
reduce unnecessary hospital readmissions
 AHA published several memos and a 2010 Health
Care Leader Guide to Reduce Avoidable
Readmissions
 Issues memo on Sept 2009 on Reducing
Avoidable Hospital Readmissions
 Includes evaluation of post acute transition
process which is the process of moving from the
hospital to home or other settings
72
AHA Guide to Reduce Readmissions
73
CMS Discharge Checklist
 CMS website recommends the discharge planning
team use a checklist to make transfer more efficient
 It is available at www.medicare.gov
 Previously research showed the value of hospital
discharge planners using a discharge checklist
 We need to dictate the discharge summary
immediately when the patient is discharged
 We need to document that it is in the hands of the
family physician
74
CMS Your Discharge Planning Checklist
75
76
CMS
 Discharge planners should be a member of the
hospital committee to prevent unnecessary
readmissions
 Discharge planners and transition coaches may
actually make the physician appointments
 Ensure medication information is clearly understood
by the patients and use pharmacists when needed
in the process
 CMS discharging planning standards start at tag
number 800
77
Things to Consider
 Form a committee on redesigning the discharge process
 Do a literature search and pull articles
 Look at the different transition studies that have been
done and which ones have been successful
 Care Transition, Transition of Care, RED, Guided care, H2H, IHI
Transforming Care at the Bedside, STAAR, Boost, GRACE,
Interact, Evercare, etc.
 Have physician dictate discharge summary as soon as
patient is discharge
 Hospitals needs to get it into the hands of the primary
care physician and document this in the chart
78
Things to Consider
 Medical staff should dictate what needs to be in the
discharge summary beyond what CMS and TJC
require
 Hospital should schedule all follow up appointments
with practitioners for the patients
 Hospital should put in writing for the patient and in
the discharge summary
 Any tests that are pending that are not back yet
 Any future tests and these should be scheduled before the
patient leaves the hospital
79
Things to Consider
 Use a discharge checklist for staff to use
 Pa Patient Safety Authority has one called “Care at
Discharge” at
http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/Pages/home.aspx
 Society of Hospital Medicine has one at
www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Tools&Template=/CM/
ContentDisplay.cfm&ContentID=8363
 Give patients a copy of the CMS checklist “Your
Discharge Planning Checklist” at
www.cfmc.org/caretransitions/patient_resources.htm or
www.Medicare.gov
 Give a list of medications with times and reason for
taking
80
Things to Consider
 Ensure education on all new meds and use teach
back to ensure education and give information in
writing
 Ensure patient is given a copy of the plan of care
 Give patient in writing their diagnosis and written
information about their diagnosis
 Have patient repeat back in 30 seconds
understanding of their discharge instructions
 Includes symptoms that if they occur what you want
to do and who to call
81
Things to Consider
 Call back all patients discharged and review
information and reinforce discharge instructions
 Have a call back number that patients and families
can use 24 hours a day, seven days a week
 Reconciling the discharge plan with national
guidelines and critical pathways when relevant
 Assess your hospital’s readmission rate
 Pull charts and review for any patient who is
readmitted within 30 days
82
Medication List
83
Appointments for Follow Up
84
Discharge Planning A-800
 Must have a discharge planning process that
applies to all patients
 Inpatients and outpatients
 P&P must be in writing
 Written discharge planning process must reveal a
clear process to be followed
 Necessary to prevent readmission
 Surveyor will review patient care plans for discharge
planning interventions
85
Identification of Patients 800
 Must identify at early stage of hospitalization,
all patients who are likely to suffer adverse
consequences if no discharge planning
 No national tool to do this
 May include factors as functional status, cognitive
ability and family support
 Patients at high risk should be identified from
screening process
 Time to do left up to the hospital but as early as
possible
86
Discharge Planning Evaluation 806
 Hospital must provide a discharge planning
evaluation to patients or upon the request of
the physician
 Needs assessment can be formal or informal
 Assess factors on what the patient will need
when discharged; bio-psychosocial needs and
patient and caregiver’s understanding of
discharge needs
 Can be a tool or protocol
87
Discharge Planning Evaluation
 Surveyor will ask how patients are made aware of
their right to request a discharge plan
 Many hospitals include this in the patient’s rights
which are given to the patient in writing
 Can also be posted in signs
 Must be given the pamphlet “Important message
from Medicare” if Medicare patient
 Patients given within 2 days of admission and must sign and
date
 Patients are given again within 2 days of discharge if admitted
more than two days
88
Discharge Planning Responsibility 807
 RN, SW, or qualified person must develop and
supervise the development of the evaluation
 Person who does discharge planning evaluation
needs to have experience and knowledge of social
and physical factors that affect functional status to
meet patient needs
 Such as in emphysema -coordinate respiratory therapy,
nursing care, financials for home health
 Must have knowledge of community resources
 Ideally, discharge planning is interdisciplinary
process
89
Evaluation 808
 Discharge planning evaluation must include
likelihood of needing post-hospital services
and availability of services
 Keep complete file on community based
services such as LTC, sub acute care, and
home care
 Is physical, speech, OT or RT needed?
 Use the QAPI program to determine if
discharge planning process is effective
90
Self Care Evaluation 809
 Discharge planning evaluation must include if
patient can do self care and return to pre-hospital
environment
 Assess willingness of patient and family to do care
 Inform patient of freedom to choose providers or
post hospital care (823)
 Give list of Medicare certified HHA that serve your area
(SSA 1861) including ownership information
 Must assess if need hospice or LTC and give list of
Medicare certified ones in your area
 Document in the medical record that the list was given
91
Discharge Planning 809
 Hospital can develop its own list or can for SNF can
also print out list from nursing home compare
website
 Surveyor to review a sample of discharge planning
evaluations
 Will note if interdisciplinary input is documented
 Counsel patient and family for post hospital care
(822)
92
Timely Discharge Evaluation 810
 Hospital must complete the evaluation timely
to avoid unnecessary delays in discharge
 So appropriate arrangements can be made
 Assessment should start soon after
admission
 Surveyor will review several patient discharge
plans for appropriate coordination of health
and social resources
93
Discharge Evaluation 811
The hospital must include the discharge
planning evaluation in the patient’s medical
record
This is necessary to establish an appropriate
discharge plan
Must discuss the results of the evaluation
with the patient
Transitions in care project show increased
utilization of home health and LTC services
94
Discharge Plan
 The hospital must make sure that the discharge
plan requirements are met (817)
 RN, social worker, or other qualified person must
develop or supervise the development of the
discharge plan if one is needed (818)
 Make sure staff are trained and licensed
 Patients have the right to participate in the
development and implementation of their plan of
care
 Physicians can request a discharge plan (819)
95
Discharge Plan
 Hospital must arrange for the initial implementation
of the patient’s discharge plan (820)
 This includes arranging for the post hospital services and
care
 This includes educating the patient about their post
hospital care plans
 Hospital must reassess the patient discharge plan if
there are factors that affect the continuing need of
the plan
 Reassessment takes place and the plan is updated as
needed
96
Discharge Plan
 Patients and family members or other interested
parties are counseled to prepare them for post
hospital care (822)
 Patients need to be kept of the progress
 May need to demonstrate or verbalize the care
need
 Teach back is good method to verify knowledge
or return demonstrations of procedures such as
emptying a foley or packing a wound
97
Discharge Plan
 If in MCO hospital must indicated which ones have
contract with home health or LTC (826)
 Hospital must now document in the medical record
that the list of home health or LTC facilities was
presented to the patient (827)
 Rewrite your P&P to include this
 Hospital must inform patient of freedom to choose
post hospital provider (828) and respect their
wishes (829)
 Disclose any financial interests
 HHA may request to be on the list
98
Transfer or Referral 837
 Must transfer or refer patients to appropriate
facilities, agencies, or outpatient services for follow
up care
 Must send along necessary medical records
 Make sure patients get appropriate post hospital
care
 Remember the federal EMTALA law for ED patients
 Must document if patient refuses discharge
planning services
 Written authorization before release of information
99
The End Questions??
Sue Dill Calloway RN, Esq.
CPHRM
AD, BA, BSN, MSN, JD
President
Patient Safety and Healthcare
Education
5447 Fawnbrook Lane
Dublin, Ohio 43017
614791-1468
[email protected]
Additional slides on TJC standards
100
Joint Commission Standard for Hospitals
 PC.01.02.01 and RC.2.01.01 EP2 Medical record
must contain information on plan of care and
revisions to the plan of care and discharge
diagnosis
 TJC has PC.01.03.01 which provided information
on planning the patient’s care
 PC.02.02.13 has end of life standards
 This is provided for reference
 Discharge planners and social workers should be
familiar with these standards in addition to the floor
nurse caring for the patient
101
Planning the Patient’s Care PC.01.03.01
 The hospital plans the patient’s care
 Need to individualize the patient’s treatment based on
their unique needs
 Treatment must be appropriate to the results of the
assessment performed
 May need to modify the plan of care based on the
assessments done
 Could result in transfer to another facility or discharge
 EP1 Patient’s care is based on what is identified by
the assessments and reassessments and the
results of the diagnostic tests
102
Planning the Patient’s Care PC.01.03.01
 EP5 The written plan of care is based on the
patient’s goals and the time frames, settings, and
services required to meet those goals
 EP22 Staff need to evaluate the patient’s progress
in light of the goals and the patient’s plan of care
 EP23 Hospital revises the plan of care and goals
based on the patient’s need
 Failure to do a plan of care soon after the patient is
admitted and maintained it in the medical record
after the patient is discharged is a top problematic
standard with CMS
103
Patient Education PC.02.03.01
 The hospital provides patient education and training
based on each patient’s needs and abilities
 Patients are often discharged home earlier than in the
past
 Patients may have to do more self care such as changing
bandages, drains to home infusion therapy
 This makes patient education even more important
 Also important to prevent unnecessary readmission
especially related to medication use
 Patient learning needs must be assessed
 Patient education is important issue to TJC
104
Patient Education PC.02.03.01
 EP10 Education and training to patient will include
the following based on the patient’s condition and
assessed needs
 Explanation of the plan for care
 Basic health practices and safety
 Safe medication use
 Nutritional interventions, diets, supplements
 Pain issues such as pain management and methods
 Information on oral health (much information later on this
including oral bacterium (periodontal disease) as cause of
cardiovascular disease, MI, VAP, stroke, CAD)
105
Patient Education PC.02.03.01
 EP10 Education and training to the patient
(continued)
 Safe use of medical equipment
 Safe use of supplies
 Rehab to help the patient reach maximum independence
 EP25 Must evaluate the understanding of the
education and training provided
 Teach back is one method to verify understanding
 Ask me three program by the National Patient Safety
Foundation
106
http://www.npsf.org
/askme3/
107
Use a Patient Education Form
108
Use a Patient Education Form
109
http://www.docstoc.com/docs/downloaddoc.aspx/?d
oc_id=35987557&pt=16&ft=11
110
Patient Education Checklist
111
Patient Education PC.02.03.01
 EP27 The hospital provides the patient education
on how to communicate concerns about patient
safety issues that occur before, during, and after
care is received
 Instructions might be to contact their physician after
discharge
 May be if certain condition reoccurs to call 911 or
go to the closest emergency department
 Patients when discharge should be informed of
signs and symptoms of when to return (TJC
discharge tracer)
112
Care After Discharge or Transfer
 PC.04.01.01 states that the hospital has a process
that addresses the patient’s need for continuing care
after discharge or transfer
 EP1 Hospital describes the reason for and conditions
under which the patient is discharged or transferred
 For example care may no longer be medically necessary
 Patient may need services that are not provided by your
hospital such as open heart surgery
 EP2 Need to describe the process for shifting
responsibility to a new clinician or hospital or service
113
Care After Discharge or Transfer
 EP3 Hospital describes mechanism for external
transfer of patient
 Example would be to contact receiving hospital and get
acceptance, fill out transfer form, send medical records,
send in ambulance when appropriate etc.
 Remember the federal EMTALA law for patients who in
the ED and are unstable
 EP4 The hospital agrees with the receiving
organization about each of their roles to keep the
patient safe during transfer
 May need transported by helicopter or ACLS or BLS unit
114
Care After Discharge or Transfer
 EP22 Patients are informed of their rights to choose
among participating Medicare providers and the
hospital does not limit those qualified providers (DS)
 EP23 and 24 During discharge planning if
determine patient needs home health or LTC then
give them a list of the ones available and document
you gave the list (DS)
 This is a CMS requirement
 The hospital can not just automatically send the patient to
their home health agency
 It is truly the patient’s freedom of choice
115
Care After Discharge or Transfer
 EP26 The hospital has written discharge planning
P&P applicable to all patients (DS)
 Must also disclose any financial interest such as the
hospital owns the nursing home or the home health
agency
 Remember to take care to prevent any unnecessary
readmissions to the hospital
 Dictate the discharge summary immediately and
document that you got it into the hands of the PCP
who is going to see the patient post discharge
116
Assessment & Discharge PC.04.01.03
 The hospital discharges or transfers the patients
based their assessed needs and the hospital’s
ability to meet those needs
 EP1 Need to begin the discharge process early in
the patient’s admission
 EP2 Identify any need for psychosocial or physical
care after discharge
 EP3 Patient, family, staff, physician, LIPs etc all
participate in the planning the patient’s discharge or
transfer
117
Assessment & Discharge PC.04.01.03
 EP4 Arrange the services the patient will need after
discharge before they leave
 EP10 The hospital conducts reassessments of its
discharge planning process within its established
time frames for reassessment (DS)
 EP11 The reassessment of the discharge planning
process includes a review of discharge plans to
determine if the discharge plans meet the needs of
patients (DS)
118
Education Before Discharge PC.04.01.05
 Before the hospital discharges or transfers a patient
is informed and educated the patient follow-up care
 EP1 When the patient needs to be discharged or
transferred this information is shared with the
patient along with the patient’s needs
 EP2 Hospital informs the patient the kinds of care
that will be needed after discharge
 Some patients will need to be in a LTC or might need
home health services or assisted living
119
Education Before Discharge PC.04.01.05
 EP3 Hospital needs to give the patient information
about why they are being discharged or transferred
 EP5 Patient must also be provided about any
alternatives to the transfer
 EP7 The hospital needs to educate the patient
about continuing care the patient will need and how
to obtain this care
 EP8 Patient must be given understandable
discharge instructions
 Remember issue of low health literacy and studies show
patients may not understand discharge instructions
120
Communication Discharge to Service Providers
 PC.04.02.01 state that when a patient is discharged
or transferred
 The hospital gives information about the care
provided to the patient
 And to other service providers who will provide the
patient with care
 Continuity of care is important so that the next treating
practitioner has the information need to take care of the
patient
 Communication is important for patient safety reasons and
to prevent readmissions
121
Communicate Information to Next Provider
 PC.04.02.01 states that the hospital must inform
other service providers who will provide care to the
patient
 When they are discharged or transferred about the
following (EP1);
 Reason for discharge or transfer
 Patient’s physical and psychosocial status
 A summary of care provided
 Patient’s progress toward goals
 List of community resources given to the patient
122
Utilization Review Plans
 2 new EPs effective January 1, 2011
 LD.04.01.01 EP 17 and 18 (deemed status)
 LD.04.01.01 EP 17: The hospital (and CAH distinct
units) has a utilization review plan that provides for
review of services furnished by the hospital and the
medical staff to patients entitled to benefits under
the Medicare and Medicaid programs. LD.04.01.01
EP 18: Utilization review activities are implemented
by the hospital/critical access hospital in
accordance with the plan