In newly revised Medicare Conditions of Participation (CoP) interpretive guidelines, the Centers for Medicare & Medicaid Services (CMS) is putting more pressure on hospitals to involve patients in decisions about their next level of care.
Published in December 2011, the
revisions include stronger language on patient rights during the discharge-planning process. For example, the guidance now stresses that “hospitals are expected to take reasonable steps to determine the patient’s wishes concerning designation of a representative.”
Ideally, this is an opportunity for case managers. Ensuring that a patient has designated a representative is an important step toward a good transition of care. A deeper pre-discharge discussion with a patient or his designee about medical and non-medical needs as well as financial resources helps a case manager develop a discharge that could prevent an avoidable readmission.
Transition of Care Is More Than a Clinical Match
Effective case managers have always put an emphasis on building a plan to meet the ongoing medical needs of the patient. That must include determining what a patient can and can’t afford. Without enough money to pay for prescriptions, medical equipment, laboratory tests or a modified diet, a patient’s health could revert to preadmission status, resulting in a readmission.
By engaging with patients or their representatives, case managers have a better understanding of a patient’s situation to help create a solid transition plan. And it’s not always a clinical discussion. As an example, the soft housing market may make it difficult for an elderly patient to sell his home, often a precursor to moving into an assisted-living facility. Because of this, more of the elderly are aging in place or moving in with family members. Conversely, an unemployed adult child who moves in with an elderly parent may become dependent on the patient’s income and home ownership. By asking the right questions before discharge, case managers can make better decisions about post-acute care.
Medicare stresses the critical role of the patient’s representative in exercising the patient’s rights. Hospital staff have the obligation to spend the time to work with patient representatives, exploring available community-living support programs, particularly in situations where the patient may be financially at risk. It isn’t enough to have the financial office help the patient apply for Medicaid.
Steps Hospital Staff Can Take
To make sure patients and their representatives receive the best options for the next level of care, hospital staff should:
- Stay Updated About Non-Medical Services. The array of non-medical, aging-in-place options is growing. Understanding the type of community-based resources that are available to patients and what is necessary to access those resources is critical. Getting effective, affordable services for health and wellness requires case managers to know the difference between private-duty home care, home-health agencies, assisted living, independent living and units for memory care. Each has a purpose and specific eligibility criteria.
- Build Community Network, Knowledge. By working more closely with all types of post-acute medical and non-medical providers, the decision about the next level of care will become clearer. As an example, if a patient is a resident in an assisted-living facility and needs skilled-nursing care, how is that care provided? If a patient needs rehabilitation services, can they be provided in the assisted-living facility, avoiding a stay in a skilled-nursing facility? If a patient is receiving services in his home from a private-duty agency and needs skilled-nursing services or medical equipment, who works with that agency to complement the plan of care?
- Understand Financial Support System. Economic factors reinforce the importance of communicating with patients, families or patient representatives. This means investigating further if a family member agrees to a plan of care with out-of-pocket expenses he probably can’t afford. Case managers need to have the financial discussion with the patient and family to ensure the choice makes sense. If the family member or representative says he can provide all needed care without outside help, be sure to ask probing questions about capability and availability. Willingness is not enough. Without a representative who is available, able and willing to provide agreed-upon support services, the patient will likely end up back in the hospital.
Jackie Birmingham, RN, MS, is vice president, emeritus, of clinical leadership at Curaspan Health Group.
This article reprinted with permission. See the original article on Curaspan’s site.
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