cms hospital conditions of participation (cops) 2013 what pps hospitals need to know about the ur...

CMS HOSPITAL CONDITIONS OF PARTICIPATION (COPS) 2013

What PPS Hospitals Need to KnowAbout the UR and Discharge Planning Standards

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Speaker Sue Dill Calloway RN, Esq

AD, BA, BSN, MSN, JD CPHRM

President of Patient Safety and Health Care Consulting

Past Chief Learning Officer Emergency Medicine Foundation

www.empsf.org

Dublin, Ohio 43017 614 791-1468 [email protected]

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The Conditions of Participation CoPRegulations first published in 1986 with the current version published December 22, 2011CMS made more than 2 dozen changes to the CMS CoP as published in the Federal Register on May 16, 2012 and effective July 16, 2012

None effected the UR/Discharge Planning standards

First published in the Federal Register and then CMS published Interpretive Guidelines and some of the standards have a survey procedure which is direction to the surveyors

The Conditions of ParticipationGood way to keep up is sign up for the Federal Register

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Hospitals should check the survey and certification website once a month for changes 2

Another good place to check monthly is the transmittal website 3

Things are published in a transmittal before being added to the CMS CoP manual

Have one person assigned to check these once a month

1 www.gpoaccess.gov/fr/index.html

2 www.cms.hhs.gov/SurveyCertificationGenInfo/PMSR/list.asp

3 www.cms.gov/Transmittals/01_overview.asp

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CMS Survey and Certification Website

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www.cms.gov/SurveyCertificationGenInfo/PMSR/list.asp#TopOfPage

CMS Transmittals

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www.cms.gov/Transmittals/01_overview.asp

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TJC Revised RequirementsTJC hospital manual has many changes

Brought their standards into closer compliance with the CMS CoP and many R&S changes

Different standards for those who use TJC for deemed status and those who do not

Example: VA Hospitals do not use TJC for deemed status since they do not apply for Medicaid or Medicare

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 that went into effect January 12, 2011

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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

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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

Mandatory Compliance

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All Interpretative guidelines under state operations manual are found at this website1

Appendix A, Tag A-0001 to A-1164 and 422 pages long

Manuals

Manuals are now being updated more frequently

Still need to check survey and certification website once a month and transmittals 2

1 http://www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf

2 http://www.cms.gov/Transmittals/01_overview.asp

CMS Hospital CoPs

Location of All of CMS CoPs Manuals

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all manuals at www.cms.hhs.gov/manuals/downloads/som107_Appendixtoc.pdf

Hospital CoP Manual Dec 22, 2011

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http://cms.hhs.gov/manuals/Downloads/

som107ap_a_hospitals.pdf

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

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

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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 basis15

Utilization Review Plan

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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

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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

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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

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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

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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, 2012 and 14 states worked

on care transition project (See MedQic)

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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

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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 planning23

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 disease24

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)

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10th Scope of Work QIO

10th scope of work started August 1, 2011 and continues for three years

Will continue efforts to prevent unnecessary hospitals and goal is 20% reduction

Has community based care transition program

Also patient safety goals as to reduce hospital acquired conditions by 40% (falls, CAUTIs, staff turnover, etc.), reduce ADEs,

Improve quality through value-based purchasing

Reduce HAI (CAUTIs, CLABSIs, CDIs, SSI)26

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 SE103727

Transmittal SE1037 1/25/2011

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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

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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?

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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?

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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?

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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?

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MedQIC

MedQIC has the quality net website with free resources for QI interventions, tools, and toolkits

http://www.qualitynet.org/dcs/ContentServer?pagename=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.

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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

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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

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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

AHA Website on RAC Program

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http://www.aha.org/aha/issues/RAC/index.html

CMS RAC Website

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http://www.cms.go

v/rac

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http://ahima.org/resources/rac.aspx

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.

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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

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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

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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

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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

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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 in-depth 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 process48

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

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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

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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

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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

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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

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Admissions or Continued StayDetermination 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)

Before determination not medically necessary, UR committee must consult the MD responsible for the care and afford opportunity to present their views

Hospital Discharge Summary Form

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Admissions or Continued Stay Then committee must provide written notification no

later than two days after determination to the hospital, patient and practitioner responsible for care

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

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

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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 process58

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

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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

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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

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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

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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-06-09-0009063

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

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AHA Guide to Reduce Readmissions

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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

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CMS Your Discharge Planning Checklist

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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

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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

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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

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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.medicare.gov/Publications/Pubs/pdf/11376.pdf

Give a list of medications with times and reason for taking

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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

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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

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Medication List

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Appointments for Follow Up

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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

So What’s in Your P&P?

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Discharge Protocol for Babies

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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

Case Management Consults

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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

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

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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 if needed to coordinate respiratory therapy, nursing care, financials for home health

Must have knowledge of community resources

Ideally, discharge planning is interdisciplinary process

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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

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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

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)

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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

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

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Patient Discharge Plan

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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)

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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

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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

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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

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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

CMS Hospital Worksheets Third Revision October 14, 2011 CMS issues a 137 page memo in the

survey and certification section

Memo discusses surveyor worksheets for hospitals by CMS during a hospital survey

Addresses discharge planning, infection control, and QAPI

It was pilot tested in hospitals in 11 states and on May 18, 2012 CMS published a second revised edition

Piloted test each of the 3 in every state over summer 2012

November 9, 2012 CMS issued the third revised worksheet which is now 88 pages

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CMS Hospital Worksheets Will select hospitals in each state and will complete

all 3 worksheets at each hospital

This is the third and most likely final pilot and in 2013 will use whenever a validation survey is done at a hospital by CMS

Third pilot is non-punitive and will not require action plans unless immediate jeopardy is found

Hospitals should be familiar with the three worksheets

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Third Revised Worksheets

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www.cms.gov/SurveyCertificationGenInfo/PMSR/

list.asp#TopOfPage

CMS Hospital Worksheets Goal is to reduce hospital acquired conditions

(HACs) including healthcare associated infections

Goal to prevent unnecessary readmission and currently 1 out of every 5 Medicare patients is readmitted within 30 days

Many hospitals (66%) financially penalized after October 1, 2012 because they had a higher than average rate of readmissions

The underlying CoPs on which the worksheet is based did not change

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CMS Hospital Worksheets However, some of the questions asked might not be

apparent from a reading of the CoPs

A worksheet is a good communication device

It will help clearly communicate to hospitals what is going to be asked in these 3 important areas

Hospitals might want to consider putting together a team to review the 3 worksheets and complete the form in advance as a self assessment

Hospitals should consider attaching the documentation and P&P to the worksheet

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CMS Hospital Worksheets The regulations are the basis for any deficiencies

that may be cited and not the worksheet per se

The worksheets are designed to assist the surveyors and the hospital staff to identify when they are in compliance

Will not affect critical access hospitals (CAHs) but CAH would want to look over the one on PI and especially infection control

Questions or concerns should be addressed to [email protected]

102

Discharge Planning

There are 23 pages in the discharge planning section and starts at page 66

Includes hospital information such as name, address, CCN number as previously discussed

Will cite deficiencies on a CMS Form 2567 if observed which is a statement of deficiencies and plan of correction when used for validation surveys

CMS discharge planning regulations and interpretive guidelines start at tag 800

103

Discharge Planning Worksheet 3rd Revision

104

Discharge Planning Worksheet

Are discharge P&P in effect for all inpatients?

Is there evidence on every unit that there is discharge planning activities?

Are staff following the discharge planning P&P?

Is there a discharge planning process for certain categories of outpatients such as observation, ED patients and same day surgery patients?

Could add questions to the assessment tool and include in questions asked in pre-admission tests for OP surgery

106

Discharge Planning Worksheet For patients not initially identified as in need of

discharge plan, is there a process for updating this based on changes in a patient’s condition?

Many hospitals have the nurse doing the admission assessment ask a set of predetermined questions to see if assistance is needed

How do you update this when there is a change?

Is a discharge plan prepared for each inpatient?

Does hospital have a process for notifying patients they can request a discharge planning evaluation?

Or process for the patient representative to request107


Surveyor will interview patient to see if they were aware they could request a discharge planning evaluation

Can the hospital show that they gave the patient a notice of their rights?

Will interview doctors and make sure they know they can request a discharge planning evaluation (819 and 806)

If doctor not aware will ask hospital to provide evidence on how it informs the MS about this

108


Will ask staff to describe the process for physicians to order a discharge plan

Does P&P provide a process for ongoing reassessment of discharge plan in case of changes to the patient’s condition (819)?

Does hospital review discharge planning process on an ongoing manner as through PI?

109

Discharge Planning Worksheet Does hospital track readmission rates as part of

discharge planning?

Does assessment include if readmission was potentially preventable?

If preventable then did the hospital make changes to the planning process?

Does hospital collect feedback from post-acute providers for effectiveness of the hospital’s discharge planning process?

This would include places like LTC, assisted living or home health agencies

110

Discharge Planning Tracers Has a discharge planning tracer section 4

Surveyors is to interview one or two inpatients

Surveyor is to review the closed medical record of two or three patients who was discharged

Will try and include one patient who was readmitted within 30 days

Will mark worksheet to show if it was an interview, discharge planning document review, medical record review or other document that was reviewed

111

Discharge Planning Tracers

Was the screening done to identify if the inpatient needed a discharge planning evaluation?

Includes at the time of admission, after an admission but at least 48 hours prior to discharge, or N/A

In some hospitals all patients get a discharge plan

Can staff demonstrate that the hospital’s criteria and screening process for discharge evaluation were correctly applied (800)?

Was discharge planning evaluation done by qualified person (SW, RN) as defined in the P&P? (806)

113


Are the results of the discharge planning evaluation documented in the chart?

Did the evaluation include an assessment of the patients post-discharge care needs?

Patient need home health referral

Patient needs bedside commode

Patient needs home oxygen

Patient needs post hospital physical therapy

Meals on wheels, etc.114


Did the evaluation include an assessment of:

Patient’s ability to perform ADL (feeding, personal hygiene, ambulation, etc.)?

Family support and ability to do self care?

Whether patient will need specialized medical equipment or modifications to their home?

Is support person or family able to meet the patient’s needs and assessment of community resources ?

Was patient given a list of HHA or LTC facilities in the community and must be documented in the record and the list appropriate (806)

115

Discharge Planning Tracers To LTC Separate set of questions if patient admitted from

LTC or assisted living

Did evaluation include if LTC has capacity for patient to go back there?

Does it include assessment if insurance coverage will cover it if they go back there?

Was the discharge planning evaluation timely to allow for arrangements if the patient needs to go back there

Was the patient’s representative involved in these discussions?

Discharge plan needs to match the patient’s needs (811, 130)

116

Discharge Planning Tracers Will look for evidence of hospital of patients and

support persons

Was patient referred back for follow up with their PCP or a health center?

Was there a referral to PT, mental health, hospice, OT etc. as needed?

Was there a referral for community based resources such as transportation services, Department of Aging, elder services etc.?

Arranged for needed equipment such as oxygen, commode, wheel chair etc.

117

Discharge Planning Worksheet If transferred to another inpatient facility was the

discharge summary ready and sent with patient?

The following controversial section was changed in the 3rd revision

Was discharge summary sent before first post-discharge appointment or within 7 days of discharge?

Was follow up appointment scheduled?

Now says send necessary medical record information to providers the patient was referred prior to the first post-discharge appointment or 7 days, whichever comes first

118

Discharge Planning Worksheet Was the necessary medical record information

ready at the time of transfer if patient sent to another facility

Was there any part of the discharge plan that the hospital failed to implement that resulted in a delay in discharge

Was there documentation in the medical record of results of tests pending at the time of discharge both to the patient and the post hospital provider?

Was patient readmitted within 30 days?

119

Preventing Readmissions

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 post-acute 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

120

121

The End! Questions???? Sue Dill Calloway RN, Esq



Chief Learning Officer of the Emergency Medicine Foundation

www.empsf.org

Dublin, Ohio 43017 614 791-1468 [email protected] Additional slides on TJC standards

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

122

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

123

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

124

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 TJC125


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)

126


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

127

128

http://www.npsf.org/

askme3/

Use a Patient Education Form

129

Use a Patient Education Form

130

131

http://www.docstoc.com/docs/downloaddoc.aspx/?doc_id=35987557&pt=16&ft=11

Patient Education Checklist

132


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)

133

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

134


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

135


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 choice136


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

137

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

138

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)

139

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

140

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

141

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

142

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 patient143

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

Discharge Planning Revised There are 22 pages in the discharge planning section

and starts at page 66

Includes hospital information such as name, address, CCN number as previously discussed

Will cite deficiencies on a CMS Form 2567 if observed which is a statement of deficiencies and plan of correction

CMS discharge planning regulations and interpretive guidelines start at tag 800

Remember hospitals with a higher than average readmission rate after Oct 2012 can be financially penalized

145


146


Are discharge P&P in effect for all inpatients?

Is there evidence on every unit that there is discharge planning activities?

Are staff following the discharge planning P&P?

Is there a discharge planning process for certain categories of outpatients such as observation, ED patients and same day surgery patients?

Could add questions to the assessment tool and include in questions asked in pre-admission tests for OP surgery

148

Discharge Planning Worksheet For patients not initially identified as in need of

discharge plan, is there a process for updating this based on changes in a patient’s condition?

Many hospitals have the nurse doing the admission assessment ask a set of predetermined questions to see if assistance is needed

How do you update this when there is a change?

Is a discharge plan prepared for each inpatient?

Does hospital have a process for notifying patients they can request a discharge planning evaluation?

Or process for the patient representative to request149


Surveyor will interview patient to see if they were aware they could request a discharge planning evaluation

Can the hospital show that they gave the patient a notice of their rights?

Will interview doctors and make sure they know they can request a discharge planning evaluation (819 and 806)

If doctor not aware will ask hospital to provide evidence on how it informs the MS about this

150


Will ask staff to describe the process for physicians to order a discharge plan

Does P&P provide a process for ongoing reassessment of discharge plan in case of changes to the patient’s condition (819)?

Does hospital review discharge planning process on an ongoing manner

Removed section that said at least quarterly

How often does your hospital do this?

151

Discharge Planning Worksheet Does hospital track readmission rates as part of

discharge planning?

Does assessment include if readmission was potentially preventable?

If preventable then did the hospital make changes to the planning process?

Does hospital collect feedback from post-acute providers for effectiveness of the hospital’s discharge planning process?

This would include places like LTC, assisted living or home health agencies

152


Has a discharge planning tracer section 4

Surveyors is to interview one or two inpatients

Surveyor is to review the closed medical record of two or three patients who was discharged

Will try and include one patient who was readmitted within 30 days

Will mark worksheet to show if it was an interview, discharge planning document review, medical record review or other document that was reviewed

153


Was the screening done to identify if the inpatient needed a discharge planning evaluation?

Includes at the time of admission, after an admission but at least 48 hours prior to discharge, or N?A

In some hospitals all patients get a discharge plan

Can staff demonstrate that the hospital’s criteria and screening process for discharge evaluation were correctly applied (800)?

Was discharge planning evaluation done by qualified person (SW, RN) as defined in the P&P?

155


Are the results of the discharge planning evaluation documented in the chart?

Did the evaluation include an assessment of the patients post-discharge care needs?

Patient need home health referral

Patient needs bedside commode

Patient needs home oxygen

Patient needs post hospital physical therapy

Meals on wheels, etc.156


Did the evaluation include an assessment of:

Patient’s ability to perform ADL (feeding, personal hygiene, ambulation, etc.)?

Family support and ability to do self care?

Whether patient will need specialized medical equipment or modifications to their home?

Is support person or family able to meet the patient’s needs and assessment of community resources ?

Was patient given a list of HHA or LTC facilities in the community and must be documented in the record and the list appropriate

157

Discharge Planning Tracers To LTC Separate set of questions if patient admitted from

LTC or assisted living

Did evaluation include if LTC has capacity for patient to go back there?

Does it include assessment if insurance coverage will cover it if they go back there?

Was the discharge planning evaluation timely to allow for arrangements if the patient needs to go back there

Was the patient’s representative involved in these discussions?

Discharge plan needs to match the patient’s needs (811, 130)

158

Discharge Planning Tracers If patient discharged home is their initial

implementation of the discharge plan?

Did staff provide training to patient including recognized methods such as teach back?

Were the written discharge instructions legible and use non-technical language (low health literacy)

Was a list of all medication patient will take after discharge given with a clear indication of any changes?

TJC revised their 5 EPs on medication reconciliation July 1, 2011

159

Medication List

160

Discharge Planning Tracers Will look for evidence of hospital of patients and

support persons

Was patient referred back for follow up with their PCP or a health center?

Was there a referral to PT, mental health, hospice, OT etc. as needed?

Was there a referral for community based resources such as transportation services, Department of Aging, elder services etc.?

Arranged for needed equipment such as oxygen, commode, wheel chair etc.

161


If transferred to another inpatient facility was the discharge summary ready and sent with patient?

Was discharge summary sent before first post-discharge appointment or within 7 days of discharge?

Was follow up appointment scheduled?

Was there documentation in the medical record of results of tests pending at the time of discharge both to the patient and the post hospital provider?

Was patient readmitted within 30 days?162

Appointments for Follow Up

163

Outstanding Labs or Tests

164

Patient Discharge Plan

165


Will look to make sure these were done and did not delay discharge

Scheduling follow-up appointments

Filling prescriptions

Pharmacist meeting with patient and/or family/support persons to review medication regimen

Pharmacist reviewing discharge medication orders prior to hospital departure

166


Will look to make sure these were done and did not delay discharge (continued):

Home setting visitation by hospital staff

Transportation arranged for follow-up appointments

Discharge planning checklists, e.g. CMS, AHRQ, CAPS checklists

Note CMS has one for patients and PaPSA and hospitalists have a checklist for physicians and staff

167

CMS Your Discharge Planning Checklist

168

www.cfmc.org/caretransitions/patient_resources.htm

Two Discharge Check Lists

This lead to the development of a formal discharge checklist to ensure communication at discharge

Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists. Halasyamani L, Kripalani S, Coleman E, et al. J Hosp Med. 2006;1:354-360

The Pa Patient Safety Authority has excellent resources including suggested elements for a discharge checklist

See Care at discharge—a critical juncture for transition to post hospital care. Pa Pat Saf Advis 2008 Jun;5(2):39-43

170

PaPSA Checklist

171

172

See Society of Hospital Medicine at http://www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Tools&Template=/

CM/ContentDisplay.cfm&ContentID=8363

173

The End! Questions??? Sue Dill Calloway RN, Esq



Chief Learning Officer of the Emergency Medicine Foundation

www.empsf.org

Dublin, Ohio 43017 614 791-1468 [email protected]

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