Discharge Planning

1. Discharge Planning Providing the right care, at the right time, in the right setting.

2. To provide classroom education on the role of case management in relationship to the discharge planning process. Purpose

3. 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.

4. 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. Program Objectives (Cont’d)

5. “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.” Definition of Discharge Planning Centers for Medicare and Medicaid Services, glossary definition. www.cms.gov

6. 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

7. 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.

8. 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

9. Key Concepts (Cont’d) • Continuous screening by Case Management during chart reviews. • Open referral policy – physicians, patients, families, or any staff member.

10. Rules and Regulations for Discharge Planning

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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.

19. Federal Regulations - Sec 482.43 Conditions of Participation: Discharge Planning: Standards Identification of needs Discharge planning evaluation Discharge plans Transfer or referral Re-assessment www.cms.gov, Hospital Conditions of Participation

20. 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)

21. 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)

22. 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

23. 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

24. 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)

25. 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)

26. 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 “75 Percent Rule” 13 Diagnoses

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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.

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. Hospital Specific Notification & Appeals Process (Insert hospital process)

47. 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

48. 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

49. Delays, LOS, and Denials:How it all fits together

50. Avoidable Days = Delays • Avoidable days are unnecessary hospitalization days. • 3 types of avoidable days: • Physician related • Department related • Continuum related