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Hospitals’ shortcomings in providing post-acute care providers with adequate discharge information prompted federal regulators to issue a special memo Tuesday.

Nursing homes and home health providers too often have been receiving patients with conditions they are not properly prepared for, putting both care providers and patients at risk, a Centers for Medicare & Medicaid Services official said in a note to state survey agency directors.

“CMS has identified areas of concern related to missing or inaccurate patient information when a patient is discharged from a hospital,” wrote David R. Wright, the CMS director of the Quality, Safety & Oversight Group. 

“[Post-acute care] providers may not be equipped or trained to care for certain conditions that apply to patients whose information they were not previously informed of by the hospital and have accepted for transfer and admission,” the memo added. “Not only can this place the patient’s health at risk, it can also put the health and safety of other residents (in the patient’s home or in a SNF), as well as provider staff, at risk. These situations can cause avoidable readmissions, complications, and other adverse events.”

Long-term care stakeholders embraced the memo’s focus. Meanwhile, a hospital industry spokesman suggested SNFs should be doing more to enable better exchange of information and CMS should be focusing more on other matters.

Some specific “areas of concern” for CMS are “missing or inaccurate information” related to patients with serious mental illness, complex behavioral needs or substance abuse problems.

Underlying diagnoses related to the mental illness or substance abuse sometimes have not been included, regulators found. In addition, there may be incomplete information passed along about specific treatments a hospital undertook, such as additional supervision needed during a patient’s stay.

Medication lists also have been incomplete. Common omissions include patient diagnoses or problem lists, clinical indications, lab results, and/or clear orders for the post-discharge medication regimen. Information omissions have been most commonly reported for psychotropic medications and hard-copy narcotics prescriptions, CMS said.

CMS said other hospital-discharge information failures have occurred regarding:

  • Treatment of skin tears, pressure ulcers, bruising or lacerations, or other skin conditions.
  • Durable medical equipment, such as Trilogy, CPAP/BiPap or high-flow oxygen which are used for respiratory treatments; also skin healing equipment such as mattresses, wound vacuum machinery
  • Patients’ goals for care and preferences for things such as advance directives and end-of-life care
  • Needs at a patient’s home, including caregiving involvement and environmental safety needs.

Overdue action?

“It’s curious that CMS would be sending this out now. It’s about 3 years too late,” Gravity Healthcare Consulting Chief Operating OfficerMelissa Brown told McKnight’s Long-Term Care News. “Before PDPM, it was common to only receive a discharge summary and a list of medications. These packets were often only 10 pages long and didn’t include a comprehensive report of the patient’s status, needs and goals. 

“Now, because of PDPM, hospitals send a fairly thorough discharge packet because the hospital documentation can be used to increase the accuracy of PDPM per diem rates. We recently reviewed a resident case with over 700 pages in the hospital discharge packet!”

She acknowledged, however, that some of the memo points “are relevant, and apply at least some of the time.”

“Often the MAR (Medication Administration Record) is not included in the hospital discharge packet,” she noted. “This is important documentation for SNFs and home health agencies to receive because it may demonstrate diagnoses or other clinical indicators that can impact care and reimbursement under PDPM and PDGM.”

She, and others, also noted that all levels of care — SNFs, home health agencies and hospitals alike — are challenged to understand and retrieve any information on the patient from before the hospital stay. 

“It often relies on the ability of the patient to provide the necessary information,” Brown observed. “This information retrieval and sharing is anemic at best and can be improved at all levels of care.”

She also added that “most” of the important patient preferences are relayed to nursing homes, “especially about end-of-life care.” Preferred discharge destination, and some other preferences, however, are not always in hospital records.

“The best bet for providers is to partner with the hospital systems in their area to establish electronic record sharing of the entire hospital medical record, including any outpatient visits that may shed light on mental health concerns, substance abuse disorders, and behaviors,” Brown said.

CMS should be commended for “recognizing this important issue,” said Denise Winzeler, RN, BSN, LNHA, a curriculum development specialist for the American Association of Post-Acute Care Nursing.

“Too often, facilities are caught off guard when pertinent information is not relayed from the hospital for new admissions,” she told McKnight’s. “This frequently impacts the quality of care the SNF can deliver to the resident. AAPACN hopes this reminder from CMS will decrease the amount of hospital readmissions and other complications that could be avoided with increased oversight regarding the transfer of comprehensive health information.”

Recommendations, resources

A leader with the American Hospital Association said hospitals have invested heavily in discharge summary reports, often with the use of electronic medical record systems or health information exchanges, where available.

“Our members will continue to emphasize the critical importance of the discharge process and hope that post-acute facilities continue to take steps to make the process more efficient and patient focused,” said Mark Howell, AHA’s director of policy and patient safety, in an email to McKnight’s.

“Moving forward, we think there are improvements that can be made to CMS discharge planning requirements that would provide for a more individualized, patient-specific approach,” he added. “We look forward to working with the agency on advancing those proposed changes.”

CMS closed its memo by reminding state agencies (SAs), accrediting organizations (AOs) and hospitals themselves of obligations to provide discharge or transferring patients and their subsequent caregivers with complete information.

“When conducting surveys, SAs and AOs should be alert to the common issues identified … and ensure these discharges are occurring in a compliant and safe manner,” it said. 

Hospitals have discretion to develop their own policies and procedures to meet discharge requirements. But CMS also offered recommendations and resources that could make the job easier.

Hospitals can use, for example, the Agency for Healthcare Research and Quality Re-Engineered Discharge (RED) Toolkit. They also can agree on standardized processes, information or forms with downstream providers. Regulators also encouraged hospitals to review past cases in order to improve future outcomes, and enable PAC providers to access electronic health records to ensure smooth, broad exchange of information.