Transition planning requirements are coming

Rhonda DePaul-DeMeno, RN, BS, MPM
Rhonda DePaul-DeMeno, RN, BS, MPM

It won't be long before we will learn what will be included in the final language of the 2014 Impact Legislation – but we can be sure of one thing – transition planning is going to be highly scrutinized under these new rules. Are you ready? How do you know? One way is to take a look at what your current facility practices are in relationship to what is coming. It is time to ask some tough questions. Let's review a few key questions your organization needs to be asking in anticipation of the changes coming down the pike.

How well does your discharge planning process work?
The rule is clear that an increase in the regulatory requirements for discharge planning is certain. It is recognized that there is a heightened need to ensure safe transitions of care, and that there is a need to strengthen the new requirements. Given the recent OIG findings on the deficiencies with current discharge planning practices, it can be assumed that providers will have to seriously evaluate their own current practices. It's probably safe to say that evaluation should start now because it's unlikely this rule change is going away.

When do you begin the discharge planning process?
Under the new proposed rules, if you don't start upon admission you're already at risk for non-compliance. The language in the rule states that the requirement would be to ‘assess a resident's potential for future discharge, as appropriate, as early as upon admission. As a matter of fact, the expectation is that you will regularly re-evaluate the patient's needs and desires on an ongoing basis and update the discharge plan throughout the course of stay.  

How involved are your patients and families in discharge planning discussions and decisions?
If they aren't at the table now, they will need to be in the future. Discharge planning will need to focus on whatever needs to be done to make sure patient goals and needs are identified, and that you have done everything you can to develop a plan with them - one that is consistent with their goals and preferences.

Who is completing your discharge plans today?
If you have one designee doing this, you should start thinking about how you will integrate a stronger interdisciplinary approach. The proposed rule requires that the IDT responsible for the development of the comprehensive plan of care should also be involved in the ongoing development of the discharge plan. There's that word again – ongoing. Discharge planning in the future won't be one and done.

Does giving the patient information on community resources – for example the Area Agency on Aging or other such resources – seem like a nice to have, not a need to have?
Not so under the new rules. Referrals to local contact agencies or other appropriate resources will definitely fall into the ‘need to have' category if the rules are finalized as proposed. And if you don't provide that information you will have to document that the patient wasn't interested in receiving it.

What are you doing to assess caregiver/support person capabilities?
Patient education is key – but that goes even farther under the proposed rules. You will be required to consider the availability of caregivers/support persons as well as their capacity and capability to perform the care required to meet patient needs after transition to the community. And it's safe to assume that if you don't think they have the necessary capacity and capability, that you address it in the discharge planning process.

What do you include in your discharge summary/recapitulation of stay?
Take a look at some of what the rule is recommending be included: diagnosis, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results, arrangements for follow-up care and post discharge medical and non-medical. How do you measure up?  The rule specifies that the discharge summary has to be provided to the patient when discharge is anticipated.

What's all this talk about ‘patient activation and patient engagement'?
The 2014 Impact Legislation makes it clear that this isn't just a passing fad. The expectation is that patients receive information that is understandable, comprehensive and, in the words of the rule, “prepares them to be active partners and advocates for their healthcare upon discharge.” This is no small task, and really puts the onus of responsibility on providers to make sure that their staff clearly understand what kind of practices create that culture of activation and engagement for patients.

Is medication reconciliation a best practice or a standard of practice in your facilities?
If it's the former then you should make the switch to the latter sooner than later. Under the new rules facilities would be, “required to reconcile all pre-discharge medications both prescribed and non-prescribed – with the patient's post-discharge medication orders.” This reconciliation should be included in the discharge summary.

What are you communicating to service providers along the continuum about the patient?
With the focus on controlling the cost of healthcare and on preventing rehospitalizations, the rule is clear that communication across the continuum is critical – and regulators will be looking for that communication in your discharge planning process. The more information you can give that next level provider, the more likely it is the transition will go smoothly and the patient will do better with it.

Where to begin?

It's kind of overwhelming isn't it? And this is just a small piece of what is included in the 2014 Impact Legislation! For providers looking to get a jump on the new rules, I'd recommend you start by:

  1. Becoming familiar with the 2014 Impact Act.  It's certainly possible that some of the proposed rules will change based upon the feedback that has been gathered over the past several months. But in the words of Margaret Mitchell, “It is better to know than to wonder.”

  2. Carefully and objectively evaluate your current discharge planning processes. Identify opportunities for improvement that are consistent with what is coming down the road.

  3. Begin process improvement now. This process would be perfect as a QAPI project.

  4. If you have multiple facilities, standardize the discharge planning process.

  5. Keep current with the evolving dialogue at the state and national level. That way you won't be surprised by something you weren't aware of.

Yes – times they are a changin' – again! But we know from years of experience in this profession that change is inevitable and our need to adjust to the change is a necessity. Improving upon the discharge and transition process is important not only to meet regulations, but to meet the emerging business realities we operate in. So take the bull by the horns and do great work!

Rhonda DePaul-DeMeno, RN, BS, MPM, is the Vice President of Strategic Development of Align, has over 30 years senior care experience, including clinical and financial operations.If you'd like more information on the contents of this blog please send your questions to: support@align30.com


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