In the Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), the Centers for Medicare & Medicaid Services (“CMS”) propose to revise discharge planning requirements under the Medicare Conditions of Participation. The objectives of the revisions include improving patient quality of care and outcomes, reducing factors that lead to preventable complications and readmissions, and promoting effective transitions of care. Seems reasonable and in line with current quality of care goals – so what changes?
More Standardization, Documentation and Communication.
Under the proposed changes, CMS will require hospitals to:
- Develop written guidance on the discharge planning process that is reviewed and approved periodically by the hospital’s governing body.
- Begin to identify discharge needs for patients within 24 hours of admission/registration – the plan must consider patient goals, needs and treatment preferences. Factors for consideration include (not exhaustive): caregiver/support person and community-based care available; patient or caregiver’s capability to perform care; relevant co-morbidities and past medical history; admitting diagnosis or reason for registration; patient’s goals and preferences; communication needs; psychosocial history; anticipated ongoing care needs; and, readmission risk.
- Regularly re-evaluate a patient’s condition to identify necessary modifications to the discharge plan – the treating physician must assist in creating the discharge plan.
- Complete discharge planning in a timely manner prior to discharge or transfer and provide detailed instruction– for patients being discharged to home (including residences and community agencies), discharge instructions (e.g., medications, follow-up appointments, etc.) must be included in the discharge plan and reviewed with the patient and/or caregiver in “teach-back” method, i.e., patient repeats back instructions to provider. Communication is key in the proposed rules including providing the patient’s primary care physician with the discharge summary and other comprehensive information within 48 hours of discharge and any pending test results within 24 hours of their availability.
Other Key Elements to Know:
- Applies to: hospitals including long-term care hospitals and inpatient rehabilitation facilities, critical access hospitals and home health agencies
- Patients/services: all inpatients; patients receiving observations services; patients being released from emergency department and identified by ED practitioners as needing a discharge plan; patients receiving same day surgery or procedures that require anesthesia or sedation
The proposed revisions were finalized for long-term care facilities in late 2016 but it remains unclear when the proposed revisions will be finalized for all facilities proposed under the rule. Will your facility be prepared? Each facility subject to the potentially changing provisions should:
- Assess their current discharge planning process
- Identify gaps
- Implement process change and written guidance
- Educate staff
Communication and documentation among hospital staff as well as communication and documentation with patients/caregivers will be crucial to comply with the proposed changes. We can help. Our DocEdgeTM Communicator mobile application allows for efficient and effective communication and documentation capture between physicians and case managers/social workers promoting expedited decision-making, updating of plans and documentation of patient needs that can be sent to the relevant system of record.
For more information on DocEdge Communicator, firstname.lastname@example.org.