New Discharge Planning Conditions of Participation (CoPs) require hospitals to assist patients, their families, or their caregivers/support persons in selecting a Post-Acute Care (PAC) provider by using and sharing data that includes, but is not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The final rule will be published on September 30, 2019 and is effective 60 days thereafter.
Almost all of the annual costs will be borne by HHAs under a new requirement that an HHA’s discharge planning process provide certain information to patients discharged or transferred to another post-acute care provider, in order to assist patients and families in selecting a provider that meets the patient’s needs and goals.
“Medicare statute provides beneficiaries with the freedom to choose their PAC provider, and the laws state that hospitals may not recommend providers,” MedPAC senior analyst Evan Christman said in his presentation. “The IMPACT Act created a new requirement that hospitals use quality data during the discharge planning process and provide it to beneficiaries. But regulations implementing this new requirement have not been finalized.”
Five Key Highlights of New Discharge Planning Conditions of Participation (CoPs)
1. Identifying Patient’s Post-Acute Needs
A hospital’s discharge planning process must identify, at an early stage of hospitalization (ideally when the patient is admitted as an inpatient, or shortly thereafter), those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning. The hospital must provide a discharge planning evaluation for those patients identified, as well as for other patients upon the request of the patient or the patient’s representative or physician.
2. Patient Assessments and Medical Records
The final rule requires hospitals to have an effective discharge planning process that focuses on the patient’s goals and treatment preferences and includes the patient and his or her caregivers/support persons as active partners in discharge planning for post-discharge care.
A hospital’s discharge planning process must identify, at an early stage of hospitalization (ideally when the patient is admitted as an inpatient, or shortly thereafter), those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning. The hospital must provide a discharge planning evaluation for those patients identified, as well as for other patients upon the request of the patient or the patient’s representative or physician.
Under the final rule, a discharge planning evaluation must assess a patient’s likely need for appropriate post-hospital services, including hospice care services, post-hospital extended care services, and home health services, and must also determine the availability of those services. CMS also established a new Patients’ Rights CoP ensuring a patient’s right to access his or her own medical information from a hospital.
3. Quality, Resource Use, and Other Measures in the Discharge Planning Process Decisions
Section 1899B(i) of the Act requires that PAC providers, hospitals and CAHs take into account quality, resource use, and other measures in the discharge planning process. Since the publication of the proposed rule in 2015, the measures implemented into the PAC Quality Reporting Program (QRPs) for the domains of functional status, skin integrity, the incidence of major falls, and the resource use and other measures as required by the IMPACT Act are now publicly available on the IRF, SNF, LTCH, and Home Health (HH) Compare websites. Data from these measures are now being reported to providers by means of private provider feedback reports.
Other data as required by the IMPACT Act will be publicly available in the near future. Providers are expected to make reasonable efforts to use the quality and resource use measure data that are currently available to them until all of the measures stipulated in the IMPACT Act are finalized and publicly reported.
Additional explanations, resources, instructions, and help on how to use the IRF Compare, HH Compare, Nursing Home Compare, and Long-Term Care Hospital Compare websites are currently available on the following pertinent websites:
- medicare.gov/inpatientrehabilitationfacilitycompare
- medicare.gov/homehealthcompare/search.html
- medicare.gov/nursinghomecompare/search.html
- medicare.gov/longtermcarehospitalcompare
Providers can use additional available information to assist patients as they select a PAC provider, so long as the information presented aligns with the patient’s goals of care and treatment preferences. The IMPACT Act in no way limits providers’ ability to augment the information provided to patients. All attempts to assist patients should be documented in the medical record. Furthermore, these discharge planning requirements do not prohibit providers from giving patients information regarding coverage of a selected PAC by the patient’s insurance or specifics on out of pocket costs for PAC providers. Providers may give this information to patients if they choose. However, providers are not expected to have definitive knowledge of the terms of a patient’s insurance coverage or eligibility for post-acute care, or for Medicaid coverage, but providers are encouraged to be generally aware of the patient’s insurance status.
“CMS Administrator Seema Verma said in a news release. “Patients will now no longer be an afterthought; they’ll be in the driver’s seat, playing an active role in their care transitions to ensure seamless coordination of care.”
In April 2019, The Remington Report’s article, “Discharge Planning: The New Focus on Patient Choice and Choosing Post-Acute Providers,” was preparing the industry for possible discharge planning changes and three ways discharge planners could select post-acute providers.
4. Patient Steering: Choice of PAC Providers
CMS believes compliance with the revised CoP and the fraud and abuse laws, including the physician self-referral law and Federal anti-kickback statute, is achievable. That hospitals, HHAs and CAHs will be in compliance with this requirement if they present objective data on quality and resource use measures specifically applicable to the patient’s goals of care and treatment preferences, taking care to include data on all available PAC providers, and allowing patients and/or their caregivers the freedom to select a PAC provider of their choice.
Providers will have to document all such interactions in the medical record. In addition, hospitals are expected to comply with the requirements in § 482.43(c) and inform the patient and/or the patient’s representative of their freedom to choose among participating Medicare providers and suppliers of post-discharge services, while not specifying or otherwise limiting the qualified providers or suppliers that are available to the patient. Hospitals, HHAs, and CAHs that have concerns that providing objective information in these circumstances may conflict with other laws can obtain guidance on the physician self-referral law at : www.cms.gov/physicianselfreferral and on the Federal anti-kickback statute at www.oig.hhs.gov.
5. Patient Transfers and Information
For those patients who are transferred to another HHA or who are discharged to a SNF, IRF, or LTCH, it is proposed at § 484.58(a)(6) to require that the HHA assist patients and their caregivers in selecting a PAC provider by using and sharing data that includes, but is not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. As required by the IMPACT Act, HHAs must take into account data on quality measures and resource use measures during the discharge planning process. In section § 484.58(a)(6), HHAs will provide data on quality measures and resource use measures to the patient and caregiver that are relevant to the patient’s goals of care and treatment preferences.
For detail of the Discharge Planning Requirements of the IMPACT Act of 2014 (Proposed § 482.43(c)(8), Proposed § 484.58(a)(6), and Proposed § 485.642(c)(8)) go to federalregister.gov/2019-20732.pdf
Additional Resources
Lisa Remington is president and publisher of the Remington Report magazine and President of Remington’s Home Care Leadership Think Tank. She has worked with more than 10,000 organizations in both a consultancy role and an educator. Lisa monitors the complex key trends and forces of change to develop a correct strategic approach to de-risk decision-making and create sustainable futures across the healthcare continuum.
