It’s been an exciting past few weeks for post-acute care. At the beginning of October, the Patient-Driven Payment Model (PDPM) went into effect for skilled nursing facilities and nursing homes. This is arguably the greatest single change to the way skilled nursing operators are reimbursed by Medicare over the past few decades – providers will now be paid based on specific patient needs and acuity rather than sheer volume of services. It’s definitely a paradigm shift for the way SNFs will operate in the future. On top of that, however, was the more unexpected final rule for discharge planning announced by the Centers for Medicare and Medicaid Services (CMS) on September 26, 2019.
CMS’ Discharge Planning Rule Supports Interoperability and Patient Preferences
The final rule empowers patients to make informed decisions about their care as they are discharged from acute care into post-acute care (PAC), a process called “discharge planning.” This rule change was required in the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) but has been languishing in proposed rulemaking since 2015. The IMPACT Act, among other things, requires hospitals to use quality data during the discharge planning process and provide it to beneficiaries.
“This is really about making sure the patient has information about what happened, in the hospital,” CMS Administrator Seema Verma said on a press call on Thursday. “And so when they do go to a post-acute provider, that they are able to have that information for the provider.”
Specifically, the final rule revises hospital discharge planning requirements for hospitals when they transition patients to post-acute care. The Conditions of Participation now state that hospitals must assist patients in choosing a post-acute care facility (skilled nursing facility, home health agency, inpatient rehabilitation facility, and long-term acute care hospital) at discharge. The hospital discharge planning process must focus on the patient’s goals of care and treatment preferences. Quality measures and resource use measures must also be used when assisting patients select a PAC provider. The rule change is intended to give patients more information about post-acute care providers when they are making a decision on where to transition to so that they can make more informed decisions.
It is well established that patients require more assistance when making post-acute care decisions. Presently, many “Medicare patients are discharged to low-value post-acute care settings with comparatively high costs and no measurable improvements in quality outcomes,” according to a 2017 Health Affairs research article. Moreover, the Medicare Payment Advisory Committee has been sounding the alarm for years about the quality of post-acute care facilities that patients go to after a hospital stay. In one report, MedPAC’s analysis of referral patterns of Medicare beneficiaries who were sent to SNFs and HHAs showed that, for many beneficiaries, another nearby provider offered better quality care: “For over 94 percent of beneficiaries who used HHA or SNF services had at least one provider within a 15-mile radius that had higher performance on a composite quality indicator than the provider they selected.”
Hospitals have long been wary of assisting patients when it comes to post-acute care selections. That is because of laws that guarantee patients free of choice when choosing a post-acute care provider. But these laws do not prohibit hospitals from assistant patients, they are more intended to prevent hospitals from steering or otherwise limiting the choice of patients. The new rule makes it crystal clear that hospitals can not only help patients in choosing higher quality post-acute care facilities, but that they are actually legally obligated to help them. Hospitals have always been permitted to use and refer patients to resources such as CMS quality measures, and even to help patients interpret that quality data. Now they are actually required to do so.
Specifically, for those patients discharged home and referred for HHA services, or for those patients transferred to a SNF for post-hospital extended care services, or transferred to an IRF or LTCH for specialized hospital services, the following requirements apply:
- The hospital must assist patients, their families, or the patient’s representative 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. The hospital must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences.
- The hospital must include in the discharge plan a list of HHAs, SNFs, IRFs, or LTCHs that are available to the patient, that are participating in the Medicare program, and that serve the geographic area (as defined by the HHA) in which the patient resides, or in the case of a SNF, IRF, or LTCH, in the geographic area requested by the patient.
- For patients enrolled in managed care organizations, the hospital must make the patient aware of the need to verify with their managed care organization which practitioners, providers or certified suppliers are in the managed care organization’s network. If the hospital has information on which practitioners, providers or certified supplies are in the network of the patient’s managed care organization, it must share this with the patient or the patient’s representative.
- The hospital, as part of the discharge planning process, must inform the patient or the patient’s representative of their freedom to choose among participating Medicare providers and suppliers of post-discharge services and must, when possible, respect the patient’s or the patient’s representative’s goals of care and treatment preferences, as well as other preferences they express. The hospital must not specify or otherwise limit the qualified providers or suppliers that are available to the patient.
The new rule is not limited to patient post-acute care choice in the hospital setting. There are several additional provisions related to discharge planning across various settings of care, including interoperability. Revised language also requires hospitals to transfer the patient’s necessary medical information (current course of illness and treatment, post-discharge goals of care, and treatment preferences), at the time of discharge, to not only the appropriate post-acute care service providers and suppliers, facilities, agencies, but also to other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. Upon request, the hospital must also ensure and support patients’ rights to access their medical records in the form and format requested by the patient, if it is readily producible in such form and format (including in an electronic form or format when such medical records are maintained electronically).
A Big Step in the Right Direction
Overall, the final rule from CMS is a huge step in the right direction for improving the way patients select and transition to post-acute acute care from the hospital and other settings. For too long, many providers have not had a formal process in place to support the transition. The status quo is typically a generic paper list of PAC options with little additional information outside of a provider’s name and address. Forcing providers to take into account and discuss PAC quality information with patients and caregivers is a big change for many hospital discharge planners. Having an informed discussion about patient PAC options and the quality data is also a gamechanger.
For the time being, CMS appears to give hospitals a lot of flexibility in exactly how they choose to implement these discharge planning changes. Regardless, the agency is clear in reminding providers that compliance with these requirements will be assessed through on-site surveys by CMS, state survey agencies, and AOs. Hospitals must document the manner in which the list of PAC providers and quality data was presented to the patient or to the patient’s representative in the patient’s medical record. CMS expects that surveyors will ask to see this documentation as part of the survey process.
The rules go into effect on November 29, 2019, so there is a lot of work to be done for many hospitals to ensure compliance with the new Conditions of Participation. Hospitals and discharge planners would be wise to start making preparations sooner rather than later to begin implementing any necessary changes to their discharge workflows. The burden of change will undoubtedly fall not just on discharge planners but case managers, social workers, and care transition nurses / nurse navigators. While these healthcare works have been getting much more involved in support patient care transitions and post-hospital care due to new value-based care payment models (bundle payments, ACOs, readmission penalties, etc.), these new rules will require them to adapt faster than ever. With less than 60 days to go before the rules go into effect, the race to get compliant with CMS discharge planning rules is on.