SNF Community Discharge Planning

Skilled Nursing Facilities Often Fail To Meet Discharge Planning

Requirements https://oig.hhs.gov/oei/reports 02/27/2013

2013 CMS Focus Areas

Safe Community Discharges

Hospital Re-admissions Patient Safety

Antipsychotic Drug Use

Oversight of Poor

Performing Centers

SNF Discharge Planning Requirements

• Clinical Summary of SNF Stay • Clinical Status at Discharge• Functional Status at Discharge • Information for Next Care Providers • Information for Patient/Family • Post Discharge Plan of Care

OIG Report to CMS

• 31% did not meet at least 1 of the discharge planning requirements

• 23% lacked post-discharge plans of care• 16% lacked adequate discharge

summaries

OIG Recommendations to CMS

• Increase regulations on discharge planning• Improve care planning and discharge planning• Hold SNFs that do not meet discharge planning

requirements accountable• Link payments to meeting requirements• Follow up on the SNFs that failed to meet care

planning and discharge planning requirements

CMS agreed with all 5 of the OIG recommendations

CMS Findings

High Medicare Re-admission Rates

Failed Rehabilitation

Premature Community Discharges

Inadequate Management of Care Transitions

$25 to $45 billion in wasteful spending in 2011 through avoidable and unnecessary hospital readmissions.” Health Policy Brief September 13, 2012

Hospital Stay

Re-admissions

SNF to Hospital 30 Day Re-admitsHealth Policy Brief September 13, 2012

Cost in Billions $$0.0

$5.0

$10.0

$15.0

$20.0

$25.0

$30.0

TotalUnnecessary

Chronic Disease & Care Transitions

Avoidable Readmissions From Community Adverse Drug Events Diabetes Cardiac Disease Congestive Heart Failure Pain Management Pulmonary Conditions Falls

Poor Care Transitions Poorly managed transitions can diminish health and increase

costs

Failed Discharge

Poor Transitions What Happens?

Patients • Don’t fully understand disease • Are confused about medications• Don’t understand test results & causes• Do not schedule follow up appointments• Cannot sustain therapy goals in home

Family members Lack proper knowledge to provide support

Preventing Poor Outcomes Well managed transitions can improve health & decrease costs

Hospital SNF Home

Prevent Poor Outcomes Problems?

• Limited Home Support • Health Knowledge

Deficit • Noncompliance • Medication Errors • Treatment Errors • Falls, Safety

Solutions!

•Stellar Discharge Planning

•Patient/Family Education

•Disease Self-Management

•Med Management

Training

•Therapy Re-conditioning

•Safety Training

Exceptional Discharge Planning

Short Term Care

• Skilled Nursing Care assessment, coordination, services

• Recovery stabilization of disease process

• Rehabilitation return of prior function

• Teaching & Training medications, prevention, mgt.

• Discharge Planning coordination of safe transition home

Medicare A Criteria

• Skilled Nursing Services• Observation & Assessment • Skilled Rehabilitation• Care Plan Development

& Management • Teaching & Training

Exceptional Discharge Planning

Begins Pre-Admission

Nursing Center Liaison Preferred patient discharge location Family and Community Support Patient & Family Education “short term care” 5 -day plan with SNF team before admit Financial data collection

Exceptional Discharge Planning On Admission Day

Discharge Team Member Meets, greets, educates patient & family Provides both listing of key facility contacts Reviews care planning process/team’s role Lists the components of short-term care Listens to patient concerns

Exceptional Discharge Planning Day Two Interdisciplinary Team Meeting

Pain evaluated, plan in place, reviewed with team Diagnoses, medications, treatments confirmed ADLs verified with nursing & therapy Financial data, days available, authorizations Preferred discharge location & support reviewed Community Discharge Plan developed

Exceptional Discharge Planning

Day Three Discharge Team Meeting Needed discharge level of function established Skilled Care plans in place {Nursing/Therapy} Skilled Observation & Assessment orders in place Discharge educational needs determined Discharge Readiness Form Initiated Goal setting call or meeting scheduled meeting prior to day seven

Exceptional Discharge Planning

Daily {M-F} Interdisciplinary Team Meetings

Telephone orders reviewed – skilled patients Projected RUG and current minutes to date Late Loss ADLs reviewed & verified {corrected prn} Discharge barriers reviewed Care & treatment refusals reviewed Potential COTs reviewed

Exceptional Discharge Planning

Weekly Interdisciplinary Team Meeting IDT Summary completed & signed Weekly Discharge Readiness Form Updated Discharge Team Member Patient Follow Up Current & Projected RUG/ARD reviewed Estimated discharge date & function noted

Exceptional Discharge Planning

5-7 Days Prior To Community Discharge Interdisciplinary Team Meeting Establish Discharge Readiness Care Plan Consider Restorative Services Begin Discharge Transition Care • Patient has written schedule – transports self to therapies • Patient demonstrates self-care teach-back as able• Patient/family complete medication management program • Patient/family complete discharge checklist with nurse• Follow up appointments scheduled & noted • Emergency numbers are reviewed

Exceptional Discharge Planning

Day of Discharge Nursing & Discharge Team Member Final medication reconciliation 5 day supply of medications Equipment in place Listing of important numbers for follow up Schedule of follow up appointments Caregiver schedules for first visits

Exceptional Discharge Planning

Day of Discharge Discharge Team Member

Completes physician follow up summary Mails physician follow up summary Schedules 3 day follow up call

Exceptional Discharge Planning

Post-Community Discharge

3 day follow-up call – discharge team member 14 day follow – up survey – admission staff

Safe Community Discharges

Sustainable Outcomes

Medication Management

Disease Mgt Education