Discharge Planning could get difficult

Hospital and skilled nursing facility (SNF) referrals are gold to home health agencies providing for patients who have a much greater need for intensive (and lucrative) services.  But that delicate relationship between a referral source and the home health agency could get much more complicated thanks to a proposed rule change from CMS.


In accordance with the IMPACT Act of 2014, hospital and post-acute providers such as home health agencies, must include in the transition process the patient’s care goals and preferred treatment.  This data is required to be collected by the providers.  Within 24 hours of admission to a hospital, all patients must have a plan for their discharge whether the patient is discharged to home/self care or to another provider (your agency).


In the process of planning the patient’s discharge options, the IMPACT Act requires that home health be a serious contender for the patient’s post-acute needs.  Patients that do not have Medicare and are enrolled in Medicaid or enrolled with a private insurance carrier must have information from a hospital on which home health agency is in network and can easily accept the patient for services.


Home health will have a very long list of requirements to be met, but many agencies already perform these duties.  Agencies will need to plan the patient’s discharge into the care of family members or support from other sources such as state Medicaid Waiver programs.  The whole goal is to avoid potential readmissions not just to a hospital, but back to the home health agency as well.  Agencies will also be required to document that the discharge plan is unique to the patient and patient needs – not just a generic agency discharge plan.


As the patient progresses or condition deteriorates, agencies will be required to update their discharge plan and constantly reevaluate the patient’s need for services, including those outside the scope of a home health agency. The physician involved with the plan of care must also be brought in to the fold in order to help determine the overall discharge plan.


The discharge plans and adjustments will be required to be kept as a part of the patient’s clinical record. All of the information, including final medication reconciliations and the patient’s final destination, including care after home health must be forwarded to the physician or accepting facility.


Information required to be part of the discharge plan that is forwarded on to other healthcare providers include a patients basic demographic information, including preferred language, immunizations, smoking status, and vital signs.  The physician responsible for signing the plan of care for home health must have contact information forwarded as well and included.  Other minimal information that is required includes procedures, diagnoses and many other elements that formulate a patient’s entire medical profile and history.


While this is just the minimal amount of information to be provided, the ability to provide all of the required elements will place a heavy burden on agencies. As most agencies do not have electronic records that integrate with other provider electronic records, forwarding this information on will likely be a cumbersome effort.  Agencies still using paper records are not going to be able to meet these needs and will be forced to use an electronic charting system.


As this is only the proposed rule, we can expect changes before the final rule is actually implemented.  While the idea seems like an overall good approach to extend the continuum of care, many agencies regularly provide this information to physicians and the next in line provider whether it be outpatient rehabilitation, hospice or non-skilled care by families or through the use of private duty services.   We will keep you posted as this develops.