Discharge Planning
Providing the right care, at the right time, in
the right setting.
Purpose
To provide classroom education on the role of
case management in relationship to the
discharge planning process.
Program Objectives
Upon completion of this program, the participant
will be able to:
• Define discharge planning.
• Discuss the rules, guidelines, and criteria
pertaining to discharge planning.
• Identify the relationship between avoidable
days, LOS, and denials and strategies to
manage all three.
Program Objectives (Cont’d)
• Discuss the role the case manager plays within
the interdisciplinary discharge planning team.
• Identify the types of continuum services
available.
• List the common barriers to discharge planning.
Definition of Discharge Planning
“A process used to decide what a patient needs for a
smooth move from one level of care to another. This is
done by a social worker or other health care
professional. It includes moves from a hospital to a
nursing home or to home care. Discharge planning
may also include the services of home health agencies
to help with the patient’s home care.”
Centers for Medicare and Medicaid Services, glossary definition.
www.cms.gov
Foundation of Discharge Planning
• Identification of needs by an interdisciplinary
team.
• Define the least restrictive environment that can
meet the patient’s needs.
• Always include patient and/or family in the
discharge planning process.
Foundation of Discharge Planning
(Cont’d)
• Educate the patient and family about community
resources that can help them maintain their
maximum potential and independence.
• Establish a safe discharge plan.
Key Concepts
• Know the rules and regulations pertaining to
discharge planning.
• All patients need to be screened on admission
for discharge planning needs.
• Key indicator for discharge planning – prior level
of functioning.
Key Concepts (Cont’d)
• Continuous screening by Case Management
during chart reviews.
• Open referral policy – physicians, patients,
families, or any staff member.
Rules and Regulations
for
Discharge Planning
Federal Regulations – Social Security
Act § 1861 (ee)
Discharge Planning Process:
“The Secretary shall develop guidelines and
standards for the discharge planning process in
order to ensure a timely and smooth transition to the
most appropriate type of and setting for post-hospital
or rehabilitative care.”
(Insert state statutes regarding discharge planning)
www.ssa.gov
Federal Regulations - Social
Security Act § 1861 (ee) (Cont’d)
Discharge Planning Process Standards
Hospitals must:
• Identify at an early stage of hospitalization
those patients in need of discharge planning.
• Provide a discharge planning evaluation for
those identified patients or upon request of
patient, representative or physician.
www.ssa.gov
Federal Regulations - Social
Security Act § 1861 (ee) (Cont’d)
Discharge Planning Process Standards (Cont’d)
Hospitals must:
• Complete evaluation on a timely basis to ensure
appropriate arrangements are in place before
discharge to avoid unnecessary delays in
discharge.
www.ssa.gov
Federal Regulations - Social
Security Act § 1861 (ee) (Cont’d)
Discharge Planning Process Standards (Cont’d)
Hospitals must:
• Include in evaluation patient’s likely need for
appropriate post-hospital services and the availability
of such services.
• Include the evaluation in the patient’s medical record
and results must be discussed with the patient or
representative.
• Arrange for the development and initial
implementation of a discharge plan.
www.ssa.gov
Federal Regulations - Social
Security Act § 1861 (ee) (Cont’d)
Discharge Planning Process Standards (Cont’d)
Hospitals must:
• Develop plan by or under the supervision of a registered
nurse, social worker, or other qualified personnel.
• Consistent with Section 1802 – not specify or limit
qualified providers, identify any provider in which the
hospital has a financial interest.
www.ssa.gov
Federal Regulations - Social
Security Act § 1861 (ee) (Cont’d)
Discharge Planning Process Standards:
Medicare+Choice
For individuals enrolled with a Medicare+Choice
organization/plan:
“The discharge planning evaluation is not required to
include information on the availability of home health
services through individuals and entities which do not
have a contract with the organization.”
www.ssa.gov
Federal Regulations - Social
Security Act § 1861 (ee) (Cont’d)
Discharge Planning Process Standards:
Medicare+Choice (Cont’d)
For individuals enrolled with a Medicare+Choice
organization/plan:
“….the plan may specify or limit the provider (or
providers) of post-hospital home health services or
other post-hospital services under the plan.”
www.ssa.gov
Federal Regulations - Social
Security Act § 1861 (ee) (Cont’d)
Applies only to patients who are admitted as
inpatient. Not applicable for patients in the
emergency department or outpatient, observation
status.
Includes:
• Medicare and Medicaid participating hospitals.
• Short-term psychiatric
• Rehabilitation
• Long-term, children’s, and alcohol/drug facilities.
Federal Regulations - Sec 482.43
Conditions of Participation:
Discharge Planning: Standards
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•
•
•
Identification of needs
Discharge planning evaluation
Discharge plans
Transfer or referral
Re-assessment
www.cms.gov, Hospital Conditions of Participation
Transfer Agreements
A hospital and a skilled nursing facility shall have a
written agreement between them for reasonable
assurance that:
“Transfer of patients will be effected between
the hospital and SNF whenever such transfer
is medically appropriate as determined by the
attending physician.”
Social Security Act § 1861 (l)
Transfer Agreements (Cont’d)
“There will be interchange of medical and other
information necessary or useful in the care and
treatment of transferred patients between
institutions or to help determine if patients can
be adequately cared for in either institutions.”
Social Security Act § 1861 (l)
Post Hospital Extended Care
Services 3-Day Stay Rule
A 3-day stay is mandatory for Medicare patients
that require placement in a Skilled Nursing Facility
(SNF) after their hospitalization.
• Counted by # of days the patient is in an
inpatient status and in his/her bed at
midnight. Observation days do not count as
part of the 3 days.
Section 1861 of the Social Security Act
Federal Regulations 10116, 10118-19
Post Hospital Extended Care
Services 3-Day Stay Rule
• This rule only applies to traditional Medicare and
typically not Medicare replacement policies.
• There is an additional 30-day window for
qualification if not discharged directly to a SNF.
• A 3-day stay is not needed if the patient is
discharged to an Acute Care Rehab or Long
Term Care Hospital.
Section 1861 of the Social Security Act
Federal Regulations 10116, 10118-19
Inpatient Rehabilitation Facility
(IRF) Prospective Payment System
(PPS) “75 Percent Rule”
The Centers for Medicare and Medicaid (CMS)
have instituted limits on the types of patients an
acute inpatient rehab facility can accept.
Section 1986 of the Social Security Act
Federal Regulation 42 CFR 412.23(b)(2)
Inpatient Rehabilitation Facility
(IRF) Prospective Payment System
(PPS) “75% Rule” (Cont’d)
• 75% of their admits must have 1 of 13
diagnoses.
(See listing on next page)
• 25% can be any diagnosis.
• It is the responsibility of the IRF to monitor the
admission diagnosis to comply with the 75%
rule.
Section 1986 of the Social Security Act
Federal Regulation 42 CFR 412.23(b)(2)
“75 Percent Rule” 13 Diagnoses
•
•
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•
•
•
•
Stroke
Spinal Cord Injury
Congenital Deformity
Amputation
Major multiple trauma
Fracture of femur/hip
Brain injury
• Neurological
disorders
• Burns
• Active arthritis
• Systemic vasculidities
• Severe or advanced
osteoarthritis
• Knee or hip joint
replacement
Stark II Regulations
Physician Self-Referral Law
“Prohibits physicians from referring Medicare patients
for certain designated health services (DHS) to an entity
with which the physician or a member of the physician’s
immediate family has a financial relationship unless an
exception applies.”
Examples: HHC, DME, outpatient therapies, laboratory, etc.
(Insert hospital specific P&P relating to physician
referrals.)
Section 1877 of the Social Security Act 42 CFR Parts 411, 424
Post Acute Care (PAC) Transfer
DRGs
A transfer DRG plays an important role in payment
when a patient with a qualified DRG is transferred to
a post acute provider earlier than the geometric
mean LOS. If a patient is admitted with a transfer
DRG and is discharged before the geometric mean
LOS, the hospital is paid using a transfer formula
which decreases the overall payment to the
hospital.
Balanced Budget Act of 1997
Post Acute Care (PAC) Transfer
DRGs (Cont’d)
• We only receive full DRG if the patient remains
past the GM LOS.
• There are 182 transfer DRGs.
(Insert Hospital Process)
Balanced Budget Act of 1997
Emergency Medical Treatment and
Active Labor Act (EMTALA)
“Hospitals must provide medical screening
examinations, treatments, and transfers of
individuals with emergency medical conditions or
women in labor regardless of the ability to pay.”
Section 1867 of the Social Security Act
Emergency Medical Treatment and
Active Labor Act (EMTALA) (Cont’d)
“An appropriate transfer should be initiated if the
hospital is unable to stabilize the patient within
its capability or if the patient requests.”
Section 1867 of the Social Security Act
EMTALA Appropriate Transfers
“The transferring hospital provides medical
treatment within its capacity that minimizes the
risks to the individual or unborn child’s health.”
“The receiving facility has the appropriate space,
capabilities, and qualified personnel for the
treatment and has agreed to accept the transfer.”
Section 1867 of the Social Security Act
EMTALA Appropriate Transfers
(Cont’d)
“The transferring hospital sends to the receiving
hospital all medical records related to the
emergency medical condition.”
“The transfer is effected through qualified medical
personnel, transportation and equipment.”
Section 1867 of the Social Security Act
Preadmission Screening and
Residential Review (PASRR)
The PASRR is an assessment used to ensure that
persons with severe mental illness (MI) and mental
retardation (MR) are identified and placed in the
most appropriate settings to meet their needs.
A PASRR screening is needed on all patients
discharging to a Medicaid certified nursing
facility regardless of payer.
The Omnibus Reconciliation Act of 1987 (OBRA) Federal Regulation –
42CFR 483.100 – 483.138
Preadmission Screening and Residential
Review (PASRR)
(Cont’d)
• Screening tools:
• Level I Screening: Identification of possible diagnosis of
MI and/or MR. Designate screener via individual
hospital P&P.
• Level II Screening: Identification of serious MI and/or
MR with placement recommendations.
(Insert screener contact information)
The Omnibus Reconciliation Act of 1987 (OBRA) Federal Regulation – 42CFR
483.100 – 483.138
PASRR Level II Exemption
Categorical Determination of
Dementia/Related Disorder:
• Primary diagnosis of dementia including
Alzheimer’s Disease or non-primary diagnosis
of dementia with a primary diagnosis that is
not a major illness.
The Omnibus Reconciliation Act of 1987 (OBRA)
Federal Regulation – 42CFR 483.100 – 483.138
PASRR Level II Exemption
Exempted Hospital Discharge:
• This exemption is allowed for individuals that come
directly from a hospital to a Nursing Facility with
the expectation that they will be discharged within
30 days from admission into the nursing facility.
The Omnibus Reconciliation Act of 1987 (OBRA)
Federal Regulation – 42CFR 483.100 – 483.138.
PASRR Level II Exemption
Advanced Group Determinations:
•Provisional admission to a nursing facility:
• Pending further assessment of delirium where an
accurate dx cannot be made until delirium clears.
Not to exceed 7 days.
• Pending further assessment in emergency
situations requiring protective services. Not to
exceed 7 days.
• Brief respite care for in-house caregivers with
placement to a nursing facility twice a year. Not to
exceed 14 days.
The Omnibus Reconciliation Act of 1987 (OBRA) Federal Regulation – 42CFR 483.100 – 483.138
Notification of Hospital Discharge
Appeals Rights
Medicare beneficiaries (primary, secondary or
tertiary) who are hospital inpatients have a
statutory right to appeal to their state QIO for an
expedited review when a hospital, with physician
concurrence, determines that inpatient care is no
longer necessary.
Section 1154 of the Social Security Act CMS-4105-F
Notification of Appeal Rights (Cont’d)
Notice – Important Message from Medicare
(IM)
• Explains discharge appeal rights.
• Hospitals must issue and explain IM within 2
calendar days of admission, and obtain the
signature of beneficiary or representative.
• Hospitals must provide 2nd IM (new or copy)
within 2 calendar days of the day of discharge
but not routinely on the day of discharge.
Section 1154 of the Social Security Act
CMS-4105-F
Notification of Appeal Rights (Cont’d)
• Beneficiaries have until midnight of the day of
discharge to appeal and be responsible for only
coinsurance and deductibles until noon of the
day after the QIO notifies the beneficiary of it’s
decision.
• Beneficiaries can still appeal after midnight of
the day of discharge but can be charged for any
hospital services received after discharge.
Section 1154 of the Social Security Act
CMS-4105-F
Notification of Appeal Rights (Cont’d)
• Beneficiary must submit request to the QIO
either via telephone or in writing.
• Beneficiary should not be discharged until QIO
review completed with outcome unless
beneficiary leaves of own accord.
• QIO notifies Hospital of appeal/request for
review.
Section 1154 of the Social Security Act
CMS-4105-F
Notification of Appeal Rights (Cont’d)
• Hospital delivers Detailed Notice of Discharge
and HINN 12.
• Hospital will provide all necessary information to
the QIO including medical record, IM, and
Detailed Notice.
• QIO has one calendar day to make a decision
after all information is received if request is
timely. Two calendar days if request is untimely.
Section 1154 of the Social Security Act
CMS-4105-F
Notification of Appeal Rights Cont’d
After QIO review:
• QIO agrees with hospital: Beneficiary is
responsible for continued stay charges
beginning at noon of the day after QIO
notification to the beneficiary.
• QIO agrees with beneficiary: No liability to
beneficiary except for coinsurance and
deductibles. Will need new 2nd notice and
discharge order from physician.
Section 1154 of the Social Security Act
CMS-4105-F
Notification of Appeal Rights
Exceptions
• Inpatient Acute to Acute transfers: Only 1st IM
needed.
• Outpatient or Observation: No IM needed.
• Admissions for non-covered or not reasonable
and necessary services: No IM needed.
• When no Part A days left: IM needed pending
days left.
Section 1154 of the Social Security Act
CMS-4105-F
Hospital Specific Notification &
Appeals Process
(Insert hospital process)
Ombudsman
“An ombudsman is an individual who assists
Medicare enrollees in resolving problems they
may have with their MCO/PHP. An ombudsman
is a neutral party who works with the enrollee,
the MCO/PHP, and the provider (as appropriate)
to resolve individual enrollee problems.”
www.cms.gov/glossary
Ombudsman (Cont’d)
“An advocate (supporter) who works to solve
problems between residents and nursing homes,
as well as assisted living facilities. Also called
"Long-term Care Ombudsman”.”
• www.cms.gov/glossary
Delays, LOS, and Denials:
How it all fits together
Avoidable Days = Delays
• Avoidable days are unnecessary hospitalization
days.
• 3 types of avoidable days:
• Physician related
• Department related
• Continuum related
Avoidable Days = Delays
• Discharge planning delays lead to extended
length of stay.
• Strategies to avoid discharge planning delays:
-Proactive discharge planning
(Insert own hospital strategies - add additional
slides as needed).
Length of Stay (LOS)
Definition of LOS
• The number of accumulated inpatient days
for a patient from admission to eventual
discharge.
Importance of Managing LOS
• National comparison to CMS GMLOS
• Throughput
• CMS Discharge Appeals Notice compliance
• Increased risk of further complications and
infections
• Financial benefits and risks
Length of Stay (LOS) (Cont’d)
Strategies for LOS management
• Proactive discharge planning
• Estimate LOS per case – each patient is
unique.
(Insert individual hospital processes)
Denials
• Denials = no payment from or repayment to
insurance companies.
• Process flow:
Delays related to discharge planning
↓
Extended length of stay
↓
Denials
↓
Financial risk to hospitals
Proactive Discharge Planning
Discharge planning starts on admission - It is
imperative that Case Management evaluates and
coordinates discharge planning early in the
process to provide for a timely discharge from the
hospital.
Include payers in discharge planning process:
• Available benefits & co-pays
• Preferred Providers
• Pre-Certification and Authorizations
• Barrier resolution
Proactive Discharge Planning (Cont’d)
• Promotes:
• Customer satisfaction:
-Patient & Family
-Physician
-Nursing
-Community partners
-Administration
• Improved outcomes
• Reductions in LOS, delays, & denials
Pro-Active Case Management
An Integral Part of the
Interdisciplinary Discharge Planning
Team
Identification of Needs
Hospital must identify all patients who are likely to
suffer adverse health consequences upon discharge
if there is not adequate discharge planning.
Federal Regulations - Sec 482.43 Conditions of Participation
Identification of Needs (Cont’d)
• All patients are entitled to a discharge plan.
• Upon admission, case managers should screen
all patients for high risk factors.
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Age
Diagnosis
Financial
Social History
Living arrangements
Mental Status
Readmission
Abuse/Neglect
Substance Abuse
Identification of Needs (Cont’d)
Daily interdisciplinary discharge planning
meetings/huddles provide an opportunity to
further identify patients for evaluation. Attendees
should include nursing, therapy, case
management, and other disciplines as needed.
Identification of Needs
(Insert individual hospital process)
Discharge Planning Evaluation
Case managers must complete an evaluation on
all patients identified as needing discharge
planning either through screening or request.
Federal Regulations - Sec 482.43 Conditions of Participation
Discharge Planning Evaluation
(Cont’d)
Evaluation needs to include a comprehensive
assessment of:
• The need for post-hospital services including
the most appropriate level of care, i.e., home,
home care, placement options.
Federal Regulations - Sec 482.43 Conditions of Participation
Discharge Planning Evaluation
(Cont’d)
• The patient’s capacity for self-care and whether
he/she can return to their previous setting:
• Evaluate the prior and current level of functioning.
• Decision-making capacity
• Mental Status
• Home environment
• Family support system
• Barriers
• The availability of services
• Requires an additional assessment of resources
available to the patient.
Federal Regulations - Sec 482.43 Conditions of Participation
Discharge Planning Evaluation
(Cont’d)
Evaluations must be timely so that appropriate
arrangements can be made.
Case managers must:
• Work with MDs, RNs, and ancillary departments.
Federal Regulations - Sec 482.43 Conditions of Participation
Discharge Planning Evaluation
(Cont’d)
Discuss evaluation results with the patient and/or
representative.
• In the event the patient and/or representative
disagrees with the evaluation/recommendations or
is slow in making a decision regarding the
recommendations, utilize patient/family conferences
to assist in goal setting with expected outcomes.
Case Management will arrange for the conference
including date, time, location, participants, and
documentation of actions. The conference should
include patient (if able), family, physician, nursing,
case management, social work, and other
disciplines as needed, i.e., respiratory, therapy, etc.
Discharge Planning Evaluation
(Cont’d)
• Communicate possible date of discharge.
• Document evaluation in the patient’s medical
record for use in establishing an appropriate
discharge plan.
• Monitor ongoing documentation of status
changes and disposition.
Discharge Planning Evaluation
Resource Assessment
Once the evaluation of needs is complete,
the case manager must identify resources
available to the patient.
Includes:
• Human resources: Availability of a caregiver,
i.e., family and friends
• Community-based resources
• Financial resources
Discharge Planning Evaluation
Community–Based Resources
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Home Health Care (HHC)
Private Duty
Hospice Care
Durable Medical Equipment (DME)
Acute Care Hospital Transfers
Acute Rehabilitation Hospitals
Long Term Acute Care Hospitals (LTACHS)
Skilled Nursing Facilities (SNF)
Extended care placement (ECF custodial)
Assisted living Facilities (ALF)
Outpatients services (Ex: Rehab, IV Therapy, Dialysis)
Other Community resources
Transportation
Home Health Care (HHC)
“Limited part-time or intermittent skilled nursing care and
home health aide services, physical therapy, occupational
therapy, speech-language pathology services, medical
social services, durable medical equipment (such as
wheelchairs, hospital beds, oxygen, and walkers), medical
supplies, and other services provided in the home.”
www.cms.gov/glossary
HHC - Skilled Care
Skilled Care requirements:
• Physician ordered
• A patient must be homebound except for
medical appointments and errands, have an
able and willing caregiver, be safe in the home
environment, and require skilled care.
HHC - Skilled Care (Cont’d)
Services provided:
• Nursing
• Personal Care
• Therapies
• Wound/Infusion Care
HHC - Skilled Care (Cont’d)
Insurance coverage
• Medicare Part A covers at 100%, must be
recertified every 60 days.
• In lieu of Part A, Part B covers as well.
• Limited Medicaid coverage per state guidelines.
• Most Medicare replacements and insurances
provide coverage pending deductibles, co-pays
and duration limits.
• Long Term Care Policy
HHC - Private Duty
No Skilled Services Needed:
Patients and families can pay for private duty
home care if custodial services are needed. (A
minimum of 3 hours and up to 24 hours per day).
• CNA: Can provide hands on care
• Companion Services: No hands on care
allowed
• Transportation
• Housekeeping
HHC - Private Duty (Cont’d)
Alternative Payment Options:
• Long term care policy.
• State funding – waiver programs.
• Indigent services available in some areas.
Hospice Care
“Hospice neither prolongs nor hastens
death.”
National Hospice and Palliative Care Organization
www.nhpco.org
Hospice Care
• Team oriented holistic approach to address a
person's physical, emotional, and spiritual wellbeing at the end-of-life.
• Hospice services are provided for end-stage
diagnoses of six months or less.
• Patient who can no longer benefit from
aggressive medical treatment.
• Physician must provide an order.
• Medicare, Medicaid, and most insurances cover
Hospice Services.
National Hospice and Palliative Care Organization
www.nhpco.org
Hospice Programs
The Hospice team is made up of physicians,
nursing, social worker/counselors, and chaplain.
Services provided include:
• Pain and symptom management
• Counseling for both patient and their loved
ones.
• Support and education to children coping with
loss of loved ones.
• Bereavement support for families after an
unexpected or impending death.
Durable Medical Equipment
(DME)
“Medical equipment that is ordered by a doctor for
use in the home. These items must be reusable,
such as walkers, wheelchairs, or hospital beds.”
• Medicare Part A & B covers the costs of DME.
• Most insurances will also cover DME if
deemed medically necessary.
www.cms.gov/glossary
Acute Care Hospital to Hospital
Transfers
For services that cannot be provided in the
current hospital setting or patient/family
request.
• A physician must request the transfer and obtain
an accepting physician at the hospital.
• For Medicare Managed Care, Managed Care
and other Insurance, follow up with payer for
authorization to transfer.
Acute Care Hospital to Hospital
Transfers (Cont’d)
• Contact potential accepting hospital for final
acceptance, bed assignment and nurse
report.
• Complete Consent to Transfer forms as
needed.
• Send a copy of all relevant medical records
including consent to transfer forms with
patient to accepting hospital.
Acute Rehabilitation Hospital
Transfers
A hospital level of care for aggressive rehabilitation
which can be within a system or free standing
facility.
• Meets 75% rule.
• The patient must be able to tolerate three
hours of therapy per day.
• For Medicare and insurance authorization and
payment must meet specific criteria/need for
intensive level of rehabilitation.
Long Term Acute Care Hospital
Transfers
LTACHs provide inpatient care for medically
complex patients who need continued hospital stay
for up to twenty five days.
• Limited availability of facilities.
• Medicare and most insurances will cover
when appropriate.
• Examples: Vent care, high tech IVs, bariatric
services, extensive wound care.
Nursing Facility Placements
Skilled Nursing & Custodial Care
Skilled Nursing Facility:
“A facility (which meets specific regulatory certification
requirements) which primarily provides inpatient skilled nursing care
and related services to patients who require medical, nursing, or
rehabilitative services but does not provide the level of care or
treatment available in a hospital.”
Custodial Care Facility:
“A facility, which provides room, board, and other personal
assistance services, generally on a long-term basis and which does
not include a medical component.”
www.cms.gov/glossary
.
Skilled versus Custodial Care
Skilled care
• Managed in a SNF
• Therapy involved
• Nursing care must be
done by a licensed
professional
• Ongoing physician
certification needed
• Covered by insurance for
limited time period
Custodial Care
• Managed in a Nursing
Home
• Care can be provided by
nurse’s aide
• Care needed for ADL’s
(bathing, feeding, etc.)
• Only covered by
Medicaid, private pay or
possible long term care
insurance
Skilled versus Custodial Care
• Medicare guidelines provides skilled care up to 100 days. 1- 20 100%
covered. 21- 100 $124.00 a day copay.
• Once a patient converts to custodial care, they must be free of skilled
care for 60 days to have the 100 days available again.
• Medicare HMO and insurance plans have specific requirements based
on type of plan.
• Insurances do not cover bed holds. Patients and/or families may
private pay to hold a nursing home bed upon admission to a hospital.
• Medicaid bed holds in nursing homes are based on SNF census and
government reimbursement to keep the bed open.
www.cms.gov
Medicare Part A
Assisted Living Facilities
“A type of living arrangement in which personal care services such
as meals, housekeeping, transportation, and assistance with
activities of daily living are available as needed to people who still
live on their own in a residential facility. In most cases, the "assisted
living" residents pay a regular monthly rent. Then, they typically pay
additional fees for the services they get.”
• ALFs are custodial care and not all provide 24-hour nursing
care.
• Some ALFs have “extended care licenses” that allow them to
do more nursing care without needing a nursing home.
• HHC can follow patients at ALFs.
www.cms.gov/glossary
Outpatient Care
Patients that need follow up care, but do not
qualify for any of the other levels of care previously
discussed or choose to attend an outpatient
program.
Ambulatory Settings
• Infusion therapy
• Wound care
• Rehabilitation services
• Dialysis
Dialysis Patients
Key areas to remember:
• Medicare typically takes 3 months to approve.
• Federal government typically does not cover
ongoing dialysis for illegal immigrants.
• Options of Peritoneal vs. Hemodialysis.
• Transportation to and from dialysis treatment.
• Schedule of treatment days.
• Strain on patients emotionally, physically
financially, work , family, etc.
Other Community Resources
• Area Agency on Aging
• Meals on Wheels
• Diagnosis related organizations i.e. American
Cancer Society
• Mental Health Providers
• Public Health Departments
• Public Transport Services
• State Department of Children and Family
Services
Transportation
All patients must be assessed for the most
appropriate mode of transportation needed:
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Private Auto
Taxi Cab
Wheelchair Transport
Medichair Transport
Ambulance – BLS, ALS
Air Ambulance
Discharge Planning Evaluation
Financial Resources
Once the level of care needs are identified, there
must be an assessment of the patient’s insurance
benefits or ability to pay for services required to
provide a safe discharge.
3 types of financial categories:
• Funded patients
• Under funded patients
• Unfunded patients
Funded Patients
• Patients that have some type of insurance for
the possible coverage of services post
discharge.
• Types of insurances include Medicare, Medicaid,
Managed Care, Worker’s Compensation, Auto
insurance, COBRA insurance, and Long Term
Care Policies.
• Insurances must be contacted for benefit
information and authorization if necessary.
Under Funded Patients
• Patients that have insurance but may lack the
benefits/coverage to adequately pay for post acute care
services.
-No HHC, SNF benefits
-Inability to pay deductibles or co-pays
• May not qualify for any Federal or state assistance.
Determine if patient and/or family can pay out-of-pocket
for services.
• Determine if any governmental, community or hospitalbased financial assistance is available on a case by case
basis.
• Use cost-benefit analysis methodology as needed.
Unfunded Patients
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Patients that lack any insurance to cover post
discharge services. Includes undocumented
immigrants.
Determine if patient and/or family can pay outof-pocket for services.
Determine if patient will qualify for any Federal,
state, community or hospital-based financial
assistance.
Use cost-benefit analysis methodology as
needed.
Cost-Benefit Analysis
A method of analyzing two or more alternatives that meet
the appropriate level of care needs to determine which
delivers the best return on the original investment.
• Used to gain support from hospital administration to
pay for post acute care services.
• Average daily cost (ADC) of remaining in the hospital
for a specified timeframe versus the cost of the post
acute care services.
• Return on investment: Days saved multiplied by the
ADC minus the total costs of post acute care services
= Cost savings.
Cost-Benefit Analysis Example
• Mrs. Doe an unfunded patient, 30 years old was
admitted with cellulitis of her bilateral extremities. She
has had an uneventful hospital stay of 3 days and is
ready for discharge but requires IVABX 2 x per day for 5
more days. Question: Should Mrs. Doe remain in the
hospital to finish the course of IVs or can she discharge
home with post acute care services for the completion of
the IVs?
• Her average hospital cost is $1000.00 per day. The
hospital has an outpatient department where she can
receive her IVABX at a cost of $100 per visit. She will
need 2 visits per day. The hospital also provides free
transportation to and from the hospital from 7:00 am until
8:00 pm.
Cost-Benefit Analysis Example (Cont’d)
Cost-Benefit Analysis:
• 5 more inpatient days in hospital ($1000 x 5
days) = $5,000.00
• Outpatient care twice a day times 5 days =
$200.00/d x 5 days =$1,000.00
• Transportation = free service to patient
• $5000 - $1000 = $4000 cost savings
Discharge Planning Evaluation
(Insert individual hospital process)
Discharge Plan
RN, SW or other qualified professional must
develop or supervise the development of a
discharge plan if the evaluation indicates a need
for such plan.
Federal Regulations - Sec 482.43 Conditions of Participation
Discharge Plan (Cont’d)
Case managers must:
• Arrange for the initial implementation of the plan.
• Reassess if conditions change.
• As needed, must counsel the patient and/or
representative to prepare them for discharge.
• Document all interventions and the patient’s
consent to the plan in the medical record.
Federal Regulations - Sec 482.43 Conditions of
Participation
Discharge Plan (Cont’d)
Case managers must:
• Provide a list of Home Health Agencies or
Skilled Nursing Facilities that are available to
the patient, participating in the insurance plan,
and in the geographic area where the patient
resides or requests.
• Document in the patient’s medical record that
the list was provided.
Federal Regulations - Sec 482.43 Conditions of Participation
Discharge Plan (Cont’d)
Case managers must:
• Inform the patient or representative of their freedom to choose
among participating Medicare providers and, when possible,
respect their preferences when they are expressed.
• Not specify or otherwise limit the qualified providers that are
available to patient.
• Identify any HHCA or SNF to which the patient is referred in
which the hospital has a disclosable financial interest. Must be
included in the discharge plan.
Federal Regulations - Sec 482.43 Conditions of Participation
Discharge Plan (Cont’d)
(Insert hospital process or forms)
Transfer or Referral
The hospital must transfer or refer patients along
with necessary medical information to appropriate
facilities as needed for follow-up or ancillary care.
Federal Regulations - Sec 482.43 Conditions of
Participation
Transfer or Referral (Cont’d)
Provide from Medical Record:
• Patient status
• Demographic – Insurance info
• Transfer Forms
• Physician notes/plan of care
• Medication Records
• Therapies
• Labs and Imaging
• Advance Directives
• All other documentation based on hospital policy or
requested by the post acute care agency/facility.
Federal Regulations - Sec 482.43 Conditions of Participation
Transfer or Referral
(Insert hospital process)
Reassessment
• The hospital and Case Management must
reassess it’s discharge planning process on an
on-going basis.
• The department’s reassessment must include a
review of discharge plans to ensure that they are
responsive to discharge needs.
Federal Regulations - Sec 482.43 Conditions of Participation
Reassessment
(Insert hospital process)
Barriers to Discharge
Planning
Sometimes, it’s like pulling a rabbit out of
your hat!
Common Barriers
•
•
•
•
•
•
•
•
•
Acuity
Age
Bariatric Issues
Bed Availability
Behavior/Restraints
Finances
Patient/Family
Physicians
Lack of Resources
Common Barriers (Cont’d)
•
•
•
•
•
•
•
Advanced Directives/DNR paperwork
Abuse and Neglect
Homeless
Legal
Transportation
Undocumented Immigrants
Incompetency Issues - Guardianship
Review Questions
1.
2.
3.
4.
True or False: Discharge Planning is a process used
to decide what a physician needs for a smooth move
from one level of care to another.
True or False: Discharge planning begins when the
discharge date is known.
True or False: Establishing a safe discharge plan is a
foundation of discharge planning.
Patient is admitted as an observation on 12/1,
converted to inpatient on 12/2. What date can they be
discharged to a Skilled Nursing Facility under
Medicare coverage?
Review Questions
1. What does the acronym PASRR stand for?
2. Name one type of avoidable day.
3. Length of stay is the number of accumulated
______ days for a patient from admission to
eventual discharge.
a. Observation
b. Inpatient
c. All of the above
Review Questions
1. A case manager must arrange for the _____
implementation of the discharge plan.
a. Whole
b. Partial
c. Initial
2. True or False: A Medicare patient does not
have the freedom to choose a specific HHC
agency or SNF for post discharge care.
3. List two common barriers to discharge
planning.
Answer Key
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
False
False
True
12/5
Preadmission Screening and Residential Review
Physician, Department or Continuum
Inpatient
Initial
False
See barrier list
References & Resources
• Balanced Budget Act of 1997
• Centers for Medicare and Medicaid Services (CMS)
– www.cms.gov
– Glossary
– CMS – 4105F
• Federal Regulations
–
–
–
–
–
Sec 482.43, Hospital Conditions of Participation
Sec 10116, 10118-19
42 CFR 483.100- 483.138
42 CFR 411,424
42 CRR 417.23 (b)2
• National Hospice & Palliative Care Organization
– www.nhpco.org
• Social Security Act – sections 1154, 1861, 1867, 1877, 1986
– www.ssa.gov
• The Omnibus Reconciliation Act of 1987 (OBRA)