Guest Columns

The heightened requirement for data-driven discharge planning

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Steven Littlehale
Steven Littlehale

It's fascinating to observe the evolution of business processes regarding transitions of care.

In July 2014, I wrote about the importance of developing effective discharge plans so as to ensure the delivery of appropriate care and safe transitions across care setting. Partially motived by the Office of Inspector General work plan, the message was clear: Responsibility for a successful transition begins at admission and extends into the community, post discharge.

Two years later, I'm struck by how the mandate has intensified with new regulatory and financial incentives.

One could argue that for skilled nursing facility providers, discharge care planning begins prior to SNF admission; it starts while the patient is at the acute-care hospital and anticipating a short-term post-acute stay, if not even sooner.

However, most SNF providers do not have visibility this far upstream. Perhaps it's more realistic to say that discharge care planning starts on day one and continues across the care continuum, regardless of care setting. A SNF provider must always ask: Could the resident receive care in a lower-acuity setting? Does he or she desire to go home? Is there a support network or reasonable physical environment in the community to support the resident's wishes?

What resident strengths could be leveraged to make this happen? What individual limitations need to be addressed? It is the resident's civil right to have these considered.

Emerging regulatory and financial incentive programs such as SNF Value-Based Payment (SNFVBP) and the IMPACT Act support these concepts and promote effective discharge planning practices.

Be it through financial incentives and penalties, or the required use of standard datasets to exchange clinical information, providers across the continuum are being motivated (by both the carrot and the stick) to change the way in which they communicate with one another and their patients for the purpose of improving transitions, mitigating risk and increasing patient safety. 

You might ask yourself what tools are at your disposal today. The answer: The MDS. However, it has become critical for providers to look beyond Section Q (Participation in Assessment and Goal Setting) and instead, focus more specifically on question Q0400: “Is active discharge planning already occurring for the resident to return to the community?”

The Department of Health and Human Services recently presented guidance for how to use the MDS for discharge care planning in which they state: “Specifically, Section Q of the MDS provides a process that, if followed correctly, gives the resident a direct voice in expressing preference and gives the facility means to assist residents in locating and transitioning to the most integrated setting.” While some may interpret this as bureaucratic paperwork (that is, until it's their rights being protected!), I would argue that this question is of utmost importance.

The MDS can broaden your view of who might successfully live in a lesser care environment. Again, ask what strengths or capacities suggest success in the community? Cognition, preferences for customary routine, functional status, mood, behavior and so many other MDS sections give insight into who might succeed.

We've used MDS data to create a predictive model that identifies residents who are likely candidates for a successful discharge —meaning they are at low risk for readmission. This model pulls data from the aforementioned MDS sections as well as others and it is highly predictive of success.

That means the residents identified do well in lesser care environments. A data-driven tool to help you advocate for the civil rights of your residents.

Using data to devise a safe and effective care plan is not only the key to success in today's metric-centric world, but it's also just the right thing to do for patients. When SNF providers approach discharge care planning as a means to a healthier community, everyone wins.

Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.

Guest Columns

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