2.  Proposed Rule by the Centers for Medicare & Medicaid Services on 11/03/2015Centers for Medicare & Medicaid Services11/03/2015  Revises the discharge planning requirements that hospitals, including CAH, must meet in order to participate in Medicare and Medicaid programs.

3.  Hospitals must develop and implement a discharge plan that focuses on the patient’s goals and preferences and prepares them to be active participants in their post-discharge care.  Discharge care must create an effective transition to post discharge care and help to reduce the factors that would lead to readmission.

4.  Plan Requirements: ◦ Be developed with input from medical staff, nursing leadership and other “relevant” departments ◦ Be reviewed and approved by the hospital governing body ◦ Documented in writing

5.  Plan Requirements: Must apply to - ◦ All Inpatients ◦ Observation patients ◦ Outpatient surgical undergoing anesthesia or moderate sedation* ◦ ER patients needing a discharge plan* ◦ Any other patients as designated by the governing body

6.  Plan Requirements: The Process – ◦ The patient’s preferences, goals and needs are to be identified resulting in a discharge plan ◦ A REGISTERED NURSE, social worker or other qualified person must coordinate the discharge needs evaluation and development of the discharge plan. ◦ Must begin to identify discharge needs within 24 hours of admission. * ◦ If discharge is in < 24 hours of admit the plan must be completed prior to discharge or transfer, without delaying the d/c or transfer.

7.  Plan Requirements: The Process – ◦ Planning process must require “regular” reevaluation to identify changes that require d/c plan modification ◦ Plan must be updated to show changes ◦ The practitioner must be involved in the process of establishing the plan ◦ Must consider caregiver/support person and community care availability and capability to perform required care

8.  Plan Requirements: Evaluation of Needs ◦ Admitting diagnosis ◦ Relevant co-morbidities and history ◦ Anticipated ongoing care needs at discharge ◦ Readmission risk ◦ Relevant psychosocial history ◦ Communication needs (language, hearing, literacy) ◦ Access to community services ◦ Patient’s goals and preferences

9.  Plan Requirements: ◦ Caregiver must be involved and informed of the plan ◦ Plan must address patient’s goals and preferences ◦ Hospital must assist patients in selecting a post- acute care 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.* ◦ Post acute care data on quality must be relevant to patient goals

10.  Plan Requirements: The Evaluation ◦ Must be: ◦ Documented in a timely manner ◦ Documented in the medical record ◦ Discussed with the patient’s representative ◦ Relevant information must be incorporated to avoid delays in d/c or transfer

11. “ The hospital must assess its discharge planning process on a regular* basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were readmitted within 30 days of a previous admission, to ensure that the plans are responsive to patient post-discharge needs.” (Use as a PI Project)

12.  Standard: Discharge to home ◦ Provide a copy of instructions to the patient and the caregiver and the post acute care provider or supplier if applies ◦ Instructions must include but are not limited to:  Care required  Written info on warning signs that will cause the need to seek medical attention, include what they should do and who they should call  Prescriptions that include name, indication, dosage along with risks and side affects of each  Medication reconciliation

13.  Standard: Discharge to home ◦ Instructions must also include:  Written instructions in paper or electronic regarding the patient's follow-up care, appointments, pending and/or planned diagnostic tests, and pertinent contact information, including telephone numbers, for any practitioners involved in follow-up care or for any providers/suppliers to whom the patient has been referred for follow-up care.

14.  Information to be sent to follow up practitioner: ◦ D/C instructions and D/C summary within 48 hours (check your MD requirements) ◦ Pending tests results within 24 hours of completion (How will you know?) ◦ All other relevant information Hospital must establish a post discharge follow up process! *

15.  Information that must be sent to receiving facility: ◦ Complete Demographics including language ◦ Physician contact information ◦ Caregiver/Support contact information ◦ Advance directive ◦ Course of illness including procedures, diagnoses, lab tests, consultations, functional status assessment ◦ Psychosocial and cognitive status, social supports ◦ Behavioral health issues

16.  Information that must be sent to receiving facility: (cont.) ◦ Medication reconciliation ◦ Allergies, immunization status, smoking status ◦ Vital signs ◦ Unique Implantable device identifier ◦ Recommendations for ongoing care ◦ Patient preferences and goals ◦ Current care plan ◦ Latest orders ◦ Any other relevant information

17.  Review the proposed rule  Evaluate your current process  Meet with medical staff, nursing administration and others to discuss  Develop processes that will help you comply  Expect JCAHO and DNV to be looking at your plan and process!!

18. Medicare Conditions of Participation, Federal Register, 80 FR 68151: https://www.federalregister.gov/articles/2015/11/03/20 15-27840/medicare-and-medicaid-programs-revisions- to-requirements-for-discharge-planning-for- hospitals#p-455