Pro-Active Case Management Strategies for Improved Throughput Discharge Planning

As defined by the Centers for Medicaid and Medicare (CMS) discharge planning is “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 (sic: case manager), 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.”

The definition as rudimentary as it is having one main component that holds the key to what must happen to ensure that patients are transitioned appropriately and in a timely manner. They must get from the level of care they are into the next level of care they are ready for when they meet that goal. Of course, devil is in the details and that is where pro-active case management/coordination comes in.

How do we define the pro-active approach. CMS tries to tell us in the conditions of participation and using the state operations manual which is the “bible” the surveyors will use to determine if you have a good system in place, they tell us the following.

§482.43(a) Standard: Discharge Planning Process

(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician.

But is this truly pro-active? According to Meriam-Webster the definition of proactive is acting in anticipation of future problems, needs, or changes. So what is the early stage of the hospitalization, day 1, 2 or more.

Many facilities and healthcare systems have policies and procedures intended to assess all patients within 24 hours but is that realistic given staffing constraints. Is 36 hours doable? How do you define the patient population in a more skilled way so that you do not miss those truly in need of pro-active discharge planning while being able to meet the survey process? CMS provides the answer.

Interpretive Guidelines §482.43(b)(1), §482.43(b)(3) & §482.43(b)(4)

For every inpatient identified under the process required at §482.43(a) as at potential risk of adverse health consequences without a discharge plan, a discharge planning evaluation must be completed by the hospital. In addition, an evaluation must also be completed if the patient, or the patient’s representative, or the patient’s attending physician requests one. Unless the hospital has adopted a voluntary policy of developing an evaluation for every inpatient, the hospital must also have a process for making patients, including the patient’s representative, and attending physicians aware that they may request a discharge planning evaluation, and that the hospital will perform an evaluation upon request. Hospitals must perform the evaluation upon request, regardless of whether the patient meets the hospital’s screening criteria for an evaluation.

The development of a high-risk screening tool/list can lead to a better method of identifying patients in need. Data analysis of past discharges of patients that had plans from case management with their diagnosis (ICD-10 or CPT codes) can lead to creating electronic notifications with an EMR as well. Once a patient presents and initial screening and documentation is initiated the alerts can be populated based on the ICD-10 and CPT codes. Staff will also be familiar with most of the high-risk categories such as the following:

1. HIGH RISK SCREENING CRITERIA:

Age:

· Age 65 or older

· Pregnant minors

· Under age 18, suspected abuse, neglect

· Individuals of all ages who are admitted from, or anticipate being, transferred to nursing home, residential care homes or specialty hospitals.

Residence:

· Group Home/Assisted Living Continuing Care Community/Senior Apartment

· Lives alone or with a non-capable caregiver.

· Patients impacted by homelessness and unstable living situations.

· Any person admitted who does not reside in the area normally served by the Hospital and who may need follow-up regarding the coordination treatment and care.

· Patients who are identified as being out of network or out of area per their insurance.

Psychological, Cognitive and Behavioral Factors:

· Attempted suicide/suicidal tendencies.

· Patients with active psychiatric feature

· Developmentally disabled, regardless of age

· History of non-compliance with health care plan

· Possible or active substance use (alcohol, chemical)

· Patients who lack capacity to make decisions on their own behalf.

· Behavioral problems that are creating barriers for transitioning out of the hospital

Social/Familial:

· Disaster Reponses

· Suspected Abuse/Neglect of children or vulnerable adults

· No known social support system

· No identification – John/Jane Doe

· Domestic violence (known or suspected)

· No next of kin and lacks capacity to make healthcare decisions and /or guardianship needed.

· Family conflict that is impacting patient care and decisions regarding care

· Patients with acute financial needs that are impacting access to recommended care.

· Readmissions within 30 days

Medical:

· Readmissions within 30 days

· Multiple visits to ED (3 or more visits in a month)

· Joint replacement

· End staged renal disease.

· Head and spinal cord injury

· Diagnosed with terminal illness.

· Needing Palliative or hospice level of care

· Hospital admission as a result of trauma

· New Diagnosis (i.e., cancer, HIV/ AIDS etc.)

· High technology – ventilators, apnea monitors

· Obstetrics – high-risk or complicated pregnancy

· Abuse – physical, psychological, failure to thrive.

· Newly diagnosed, untreated, or advanced HIV/AIDS

· Nutritional problems – TPN, tube feeding, cachexia etc.

· Handicapped – visual, hearing, paralysis and other progressive degenerative or debilitating conditions.

Nursing Care/ Social Services:

· Patients in need of follow-up treatment, teaching and/or referral to other agencies (i.e., home care, day care etc.)

· Patients who may require home specialty equipment/ durable medical equipment.

· Patients requiring supportive care (i.e., transportation assistance)

· Patients with changes in body image (stoma, plastic repair, burn)

The list is not exhaustive but will capture about 85% of all patients and having been surveyed many times including by the Washington DC CMS team while a Director in Maryland and being told the high-risk criteria was one of the best they had seen I have been a big proponent of using it everywhere I have been a leader.

Another key area in the proactive discharge planning process with the proliferation of managed care is the inclusion of the care management team from the insurance companies in the d/c planning process. You will want to discuss at a minimum the following:

• Available benefits & co-pays

• Preferred Providers

• Pre-Certification and Authorizations

• Barrier resolution

By including them early in the process you may save days in the back end waiting for an authorization as well as providing the patient/family/caregiver the options available in their network.

I would be remiss without discussing the importance of communication with the interdisciplinary team on the clinical progress of the patient so that anticipatory action can take place on the expected discharge date. Using the clinical milestones from the physician’s plan of care and the progress the patient is making to overcome their illness or injury is a key to ensuring throughput is achieved. Balancing the clinical outcome with any potential barriers such as social determinants of health that are discovered and addressing those early on through proactive planning will lead to reduced length of stay. Communication at each stage of change is a key element to overcome the barriers that may impede a healthy plan from being successful.

The better informed the patient and their family/caregiver is from an early stage the more successful the discharge plan. This is evident in the regulations as well as in well run facilities with low LOS and good throughput.

§482.43 Condition of Participation: Discharge Planning

The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions.

Proactive discharge planning means starting early, assertively and with good assessment of the identified high-risk patients that will need coordination for movement to the next level of care. Attention to the details of each plan and inclusion of the patient/caregivers along with the interdisciplinary team at a early stage can assist with most barriers to help reduce the majority of the high burden patient population that make up the 5-10 day LOS patient population thus having a major impact on the overall LOS and throughput.