By Evan C. Reinhardt, Indiana Association for Home and Hospice Care
Transitions in the world of healthcare are challenging for providers even under the best of circumstances. Sending a patient home from the hospital is often the culmination of days or weeks of work on patient care that are combined with helping the patient navigate to their next provider and/or setting. Often, just choosing a provider can be one of the more difficult steps to take.
On the receiving end, the subsequent provider must do their best to understand the background for the patient and begin to assemble a team to provide care for him or her that can meet all of the needs identified. Again, no mean feat even when all goes as planned. And the financial impact of readmissions penalties and possible decrease to quality scores, among other impacts, all loom in the background as potential consequences for any negative outcome.
In order to more formally address the discharge process, the Centers for Medicare and Medicaid Services (CMS) recently released a rule that sets out increased requirements for hospitals that transition patients to Post-Acute Care (PAC) providers. The rule requires hospitals to provide information to patients as they move throughout the healthcare continuum. Providers impacted by this requirement include hospitals, long-term care hospitals, critical access hospitals, psychiatric hospitals, children's hospitals, cancer hospitals, inpatient rehabilitation facilities and home health agencies.
Key performance data, including the number of pressure ulcers, proportion of falls that lead to injury, and the number of readmissions back to the hospital must all be provided to the patient or their representative. The discharging facility must also document how their care team has assisted patients and/or their representatives in selecting a PAC provider by sharing this performance data, which also must be "relevant and applicable to the patient's goals of care and treatment preferences," according to CMS.
In addition, the rule requires facilities and home health agencies to send specific medical information when patients are transferred to another facility along with an evaluation of the patient's need for post-hospital services that might include: hospice and post-hospital extended care services, home health services and non-health care services and community-based care providers.
CMS did indicate this requirement formalizes some of what hospitals and PAC providers were likely already doing in the field, but there are new details in the discharge-planning arena that providers will need to become familiar with.
The final rule can be found here.
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