Understanding how IMPACT Changes Discharge Planning

Original story posted on: December 5, 2018

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Proposed changes will impact hospitals, critical access hospitals, inpatient rehabilitation facilities, and home health agencies.

The Centers for Medicare & Medicaid Services (CMS) back in 2015 proposed changes to the Conditions of Participation (CoP) found in 42 CFR part 482. The rationale for the changes is provided in elegant detail in the Federal Register, under the title “Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for hospitals, Critical Access Hospitals (CAHs), and Home Health Agencies (HHAs).” In a few words, erosion of quality of care and readmissions are a failure of discharge planning in a world where hospitals are increasingly responsible for post-acute outcomes.

These changes to the CoP are inseparably linked to the Improving Medicare Post-Acute Transformation Act of 2014 (IMPACT). IMPACT asserts that patients often are not adequately prepared for discharge, and hence return quickly to the hospital or experience other poor outcomes. In passing IMPACT, Congress directed the U.S. Department of Health and Human Services (HHS) Secretary to makes changes in the CoP to force important improvements in discharge planning:

  1. Providing quality ratings of post-acute providers when providing choice of providers;
  2. Putting extra effort in the discharge needs evaluation to learn as much about the patients’ unique post-acute situations as possible (functional status, adaptive equipment, living situation, caregivers for examples) early in the stay; and
  3. Providing mental health and what is now called psychosocial determinates of health included in the discharge, followed by evaluation.

In a CMS national town hall in early 2015, I asked straight-up about informing patients of quality ratings and the impact that would have on patient choice. Quality rankings are notoriously flawed, regardless of the source. In an area with limited post-acute providers or very restricted networks payors use to control costs, there is no getting away from potentially subpar providers. Given the choice, patients will always choose providers that are paid for by insurance.  

The answers were, to paraphrase, “we understand, but too bad.” Market pressures will solve everything. It is up to the consumers to complain. Offer choices and provide quality ratings.       

About HHA inclusion, I have reason to support change: hospital readmission from HHAs is not substantially different from discharges to self-care at home. This is my hospital’s experience. Try this for yourselves: take your hospital’s total readmissions, and then break them down by disposition and compare. Your analysis may reveal different conclusions, but CMS is seeing the same things as were gleaned from my observations.

HHAs and hospitals have a common problem. In a budget-neutral payment system, reimbursements are cut. Feeling the financial pinch, there is a push to control LOS. Parenthetically, researchers in England observed that short lengths of stay (LOS) and particular discharges from observation status are linked to readmissions within a short time from the index stay. Those who perform analysis of readmissions at my hospital agree (just saying). And maybe, just maybe, time for discharge planning gets shorted and staffing for social work and case management is inadequate for the new requirements. 

Partly out of striving for excellence, but mostly from fear (my strongest motivator) of believing that changes to 42 CFR Section 482.43 were imminent, I and my counterparts in other nursing units put new processes in place. Evaluation is now completed and shared with the attending within 24 hours of admission regardless of status. The nursing unit has a detailed discharge instruction process that includes follow-up visits to PCP and specialists, medication reconciliation, and what to expect when you get home. Collaboration with social work and case management is tight. If it sounds expensive, yes, it is. But improvements in patient and physician satisfaction have been amazing. Most believe that only so much reduction in one’s readmission rate is possible, even when moving to a relative improvement rate method. But with close cooperation and planning, more patients here are referred to hospice end-stage disease management programs, in which patients can live years without readmissions. Frankly, I gave up on readmission rate worries, instead focusing on what impact we can have in patients’ quality of life and self-management. New people moving into the area will manage somehow to muck up readmission rates.

Read IMPACT and proposed changes to 42 CFR 482 carefully. The law practically writes your policies and procedures for you. There is so much information out there about impacting psychosocial determinates. Some are very elegant and expensive, but there are many things that can be done with changes in case management, social work, and nursing processes. Talk to your CFO about the best way to operationalize the changes. He will be happy in the end.




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Marvin D Mitchell, RN, BSN, MBA

Marvin D. Mitchell, RN, BSN, MBA, is the director of case management and social work at San Gorgonio Memorial Hospital, east of Los Angeles. Building programs from the ground up has been his passion in every venue where case management is practiced. Mitchell is a member of the RACmonitor editorial board and makes frequent appearances on Monitor Mondays.

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