To safeguard Medicare and Medicaid beneficiaries’ health and safety, the Centers for Medicare & Medicaid Services (CMS) develops and publishes Conditions of Participation (CoPs) and employs designated organizations to assess compliance with CoPs. In addition, Appendix A of the State Operations Manual contains CMS survey interpretative guidelines..
For case managers and case management leaders, the discharge planning CoPs athelp guide their daily work with patients, setting the minimum requirements for providing appropriate transitions of care. As hospital stays get shorter and the patient population gets older, the challenges of arranging a safe and effective discharge plan grow. And that challenge increased in 2019 when CMS updated the CoPs for discharge planning in September 2019.
Most of the discussion around that update centered on the issue of patient choice, with CMS adding the requirement that patients be offered a choice of not only home health agencies (HHAs) and skilled nursing facilities (SNFs) as required in the past but also inpatient rehabilitation facilities and long-term acute care hospitals. This addition, though, was also accompanied by a statement that “We expect discharge planning to facilitate patient choice in any post hospital extended care services, even though the statute does not require a specific list beyond HHAs, SNFs, IRFs [inpatient rehabilitation facilities], and LTCHs [long-term care hospitals].” This would mean that choice should also be offered for hospice and durable medical equipment (DME) where applicable.
The issue of choice for SNFs has led to some ambiguity in interpretation. CMS states that patients must be presented with a list of SNFs available to the patient and in the geographic area requested by the patient. CMS expressly said that providers may not limit the list to those facilities that have agreed to accept the patient. That leads to the dilemma of the patient choosing a facility that can provide the post-acute care they need but does not have an open bed at the time. Must that patient choose another facility with an available bed, or can the patient insist on staying in the hospital without any financial liability until their preferred facility has an open bed? The answer is unknown, but it is hoped that CMS will address this in the interpretive guidelines once they are released.
On the other hand, in a June memo to survey organizations, CMS was unambiguous in stating that they are concerned that hospitals are not complying with the CoPs for discharge planning in several areas. While complying with every CoP is required, those specifically called out by CMS in such a memo should alert every provider to confirm that their processes meet both the letter and spirit of the regulation. CMS noted six areas that warranted extra scrutiny by the survey organizations, all related to providing information to post-acute care providers.
First mentioned is the omission of information related to patients with serious mental illness, substance use disorder, or complex behavioral needs. While details are not provided, their description suggested that hospitals did not relate to post-acute care providers the need for interventions to control behavior during the hospital stay that was discontinued prior to discharge. For example, a patient may have required a sitter at some point during their hospitalization. While the sitter was not required on transfer, CMS notes that such information would be crucial to convey so the post-acute care provider can be prepared if behavioral issues recur.
List of medications, skin issues, DME needs, etc.
Medications were addressed in the next issue. CMS noted that patients are being transferred without a list of medications they received “during and before their hospital stay.” They note that, at times, patients are not transferred with a list of medications to be continued; it specifically states that patients requiring controlled substances are not sent with a written prescription for such, which is required for the post-acute care provider to continue such medications until the facility physician sees the patient. It was also noted that patients received psychotropic medications that were not noted on the transfer paperwork. As with behavioral issues requiring physical interventions, understanding the hospital pharmacological needs of the patients could be critical for the providers in the post-acute care settings.
Surprisingly, CMS also noted the omission of skin issues, such as tears, ulcers, surgical incisions, and the exclusion of care instructions. The lack of documentation from the wound care staff or instructions from the surgeon for care of the surgical site subjects the patient to an increased risk of wound infection and other complications.
CMS also notes that patients arrived at post-acute care facilities where the facility was not informed that the patient required specialized DME. Few, if any, post-acute care facilities stock DME, as hospitals do. DME used there must be ordered from their supplier and delivered to the facility. If the patient required continuous positive airway pressure at night and the DME provider could not deliver that day, the patient’s health would be in jeopardy.
While assessing a patient’s social needs is a standard for hospital case management, it appears that some are not conveying that information to the post-acute care provider. Many would say that while we still have no solution for many for food insecurity or many of the other social determinants of health, it would be vital for a post-acute care facility to know that a patient is homeless as they will soon be faced with planning for that patient’s discharge from their facility.
CMS remains objective, noting that these omissions occurred and were brought to their attention without providing any commentary. However, these four issues suggest that if one were to speculate with a pessimistic view, a hospital omits information that would lead a post-acute care provider to not accept a patient for post-acute care. On the other hand, although hospital stays are shorter than in the past, the amount of information generated seems to have expanded exponentially, and inadvertent omissions of such information are certainly within the realm of possibilities.
In the 2019 revisions to the discharge planning CoPs, CMS noted several times that they expect hospitals to evaluate and honor patients’ treatment preferences and goals of care. In the Federal Register commentary, CMS used “treatment preferences and goals of care” 53 times in the 201-page rule, enforcing that they are serious about the requirement. And in this memo, CMS notes that hospitals are not relating that information to the post-acute care provider, especially calling out preferences for end-of-life care. It is horrendous to think that a patient underwent resuscitation because a hospital did not convey that patient’s desire not to be resuscitated to the post-acute care provider.
Patient transitions of care are one of the most complex parts of healthcare. Be it sending a patient home after a brief hospital stay with proper medication reconciliation and appropriate follow-up arrangements or transferring a patient after a complex admission that included intensive care to a post-acute care provider, there are ample opportunities for errors of omission or commission. Even a brief hospital stay can generate hundreds of pages of medical records, and the staff may miss the necessary information at the accepting facility. The transferring staff may have been unaware that the patient required a sitter two weeks prior to transfer. The post-acute care provider may have been informed that the patient had specific DME needs, but that information was not conveyed within the facility.
Nonetheless, CMS felt compelled to issue this memo to alert all hospitals to assess their processes for patient transitions to post-acute care providers, especially in the areas outlined in the memo. While CMS does not formally endorse the use of external products, the memo includes links to two tools that can be used to improve transitions. Improved transitions to post-acute care providers may not be the most appealing of duties; to our patients, the presence or absence of a comprehensive process could be crucial to their health and safety.
Patient safety depends on complete and accurate transitions of care from hospitals to post-acute care providers.
The Centers for Medicare & Medicaid Services has noted a pattern of deficiencies that led to releasing a special memo to survey organizations to ensure compliance.
Hospitals must ensure that post-acute care providers are notified of the patient’s need for behavior control modalities at any time during a hospital stay, perform proper medication reconciliation, including providing written prescriptions where required, inform the provider of any durable medical equipment needs, and describe any skin care needs.
A patient’s treatment preferences and goals of care must be ascertained and conveyed to any post-acute care provider.
The release of this memo to survey organizations should lead hospitals to ensure their processes for transferring a patient to a post-acute care provider are comprehensive and accurate.