Guest Columns

Don't drop the ball when the music ends: creating the right discharge plans

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Steven Littlehale
Steven Littlehale

In 2013, the OIG released the results of a study titled, “Skilled Nursing Facilities Often Fail to Meet Care Planning and Discharge Planning Requirements.” The study found that in 31% of the Medicare stays reviewed, facilities did not meet one or more requirements for discharge planning and documentation.

Of course, this report is concerning since many of the residents/patients we discharge have significant issues. PointRight found that in 2012, over 2 million people were discharged from the SNF setting to the community. More than half of these people were at high risk for falls, and almost 25% had significant symptoms of dementia. With these risk factors, safe discharges require complex care planning.

To ensure a safe discharge along the healthcare continuum, your interdisciplinary team works together with the resident, his or her family or responsible party, and other providers to plan for their care transition. Effective planning is based on an accurate assessment of the resident's needs. It begins on admission and is formulated and tested during the stay. A care plan pulled together the day of discharge, or even the day before, is usually ineffective.

SNFs without effective discharge planning processes can put their residents at risk, and may be at risk for poor reputation, loss of referrals, regulatory citations, and likely financial penalties in the future. The OIG's recommendations to CMS included regulations related to care planning and discharge planning, increased surveyor scrutiny in these areas, and possibly linking payment to compliance.

CMS agreed with all of these recommendations, which should be motivation enough to make providers sit up and take notice.

So what's the take away from this? A successful discharge is all in the planning and communication. Consider adding some or all of these to your process:

  • Establish resident/patient-centric goals, not facility or payer centric.
  • Use MDS-based predictive analytics to identify areas of risk that go beyond rehospitalization, but may compromise the resident's goals and stall the discharge plan.
  • Conduct data-driven referrals — high risk areas must be mitigated prior to discharge home. Appropriate referrals, education and a “warm handoff” will make for a more successful transition.
  • Leverage the MDS in this process, and consider a QAPI plan if needed. Monitor Section Q; if an active discharge plan is indicated and a referral needed, was it made?

Providing for a safe handoff is the SNF's responsibility. CMS is increasing its scrutiny of this issue, monitoring for non-compliance. The potential for survey and financial penalties exists.  Remember that the efforts you make to meet the standards for discharge planning will pay off in the quality of life of your (former) residents!

Steven Littlehale is a gerontological clinical nurse specialist and former university instructor.

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Guest Columns

Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.

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