And now, I would like to introduce our speaker to get us started today. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as a Director of Facility, Patient Safety, and Risk Management and Operations for COPEC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPEC, she served as the Director of Western Region, Patient Safety, and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jurisprudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. Thank you for being here with us this morning, Laura, and we invite you to get us started. Okay. Thank you, everyone, and thank you very much, Lindsay. Today's topic is discharge planning, and that recently came to light with CMS just a couple years ago when they were doing the hospital improvement rule and some of the previous and in-depth research that CMS had done to find out, okay, what are we doing or what can we improve upon so patients aren't readmitted? And that was the magic word that was avoiding those preventable readmissions, and that's how discharge planning came to be. Now, I just want to make one quick note here. If you have a specific question for CMS as it relates to your hospital, especially if you're looking for a potential survey coming up, email them with your question. I have their email addresses here on my second slide. They just give them a little time, but if you can be as concise as possible, they're really good about getting back to you, and keep that so that if it does come up during the survey, you're ready to go. Now, why are we here today? Well, a couple of reasons. One is so you don't get one of these, and that is the Statement of Deficiencies and Plan of Correction, where they have found condition-level issues that you need to meet. Now, if you don't complete that plan of correction, this is something, of course, nobody wants to happen, and that is the Notice of Involuntary Termination from the Medicare and or Medicaid Agreement. And again, that happens when you don't do a plan of correction. The plan of correction is insufficient, or that the plan of correction just doesn't quite meet those expectations that CMS is hoping. The regulation itself starts in the Federal Register. That's where it's published. And then CMS has a couple of responsibilities. One is to notify their surveyors and the state agencies, hey, this is what's new. And that comes out in what's called a transmittal. They also have to develop interpretive guidelines and survey procedures. And the guidelines give the rationale behind that regulation or what CMS expects to see. Now those interpretive guidelines, which we do go through today, they have a lot of information you will never find in the regulation. So that's why you really need to read them together. And then, of course, they have to update the manual when they come out. Three types of surveys, most of you are familiar with them. The certification right at the beginning, then a validation if they have to come back out or they're following an accrediting organization. And then the complaint survey, again, no one ever wants to get one of those. The good way to keep up with the changes, because sometimes, and it doesn't matter what time of year, CMS will put out a new regulation or a new interpretive guideline, subscribe first off to the Federal Register, because then you will get notice when that new regulation comes out. Of course, you want to make sure you have the most recent manual. And then anything after that will be in what's called a transmittal page. I'll show you how to get to those, by the way. And then the survey and certification site. The manual first came out in 86, multiple updates since then. Slide number five has the links. You will have to copy paste them to your CIRF engine. But overall, this is the appendix for CMS, page one. And this incorporates and has all of those areas for healthcare that CMS has the responsibility to have oversight. Hospitals are A, criticals, your appendix W. A couple others you want to keep track of. What happened to be appendix Q, that's immediate jeopardy. That's when, oh, dear, something terrible's happened, and they might be out, like, within two business days to do a survey. On the manual itself for appendix A, you can see in the red lettering, yours first came out in, or excuse me, last came out in April of this year. So that's why you want to make sure you have the most recent manual, because what was in the previous one may not have been there, is there now. And then, of course, for appendix W, yours is the same way. Now, your manual has not been updated since 2020. I have asked when that will be updated, because there's changes that still need to go in there. But they haven't given me a date on that. And then again, the transmittals. When you're in the website, that's where you can hit the blue lettering to go to that transmittal page. Again, please use the transmittal page, because it's the easy way to find out the new changes. And so for the last one, for appendix A, again, yours came out April, and they put in there the revision. There were very few revisions, and it only had to do with informed consent. But that's just, this slide here, slide number 11, will show you what does that transmittal page look like. Again, what's revised, what's new, and what happens to been deleted. On the memo site, you might want to check it monthly. Anything more than that, you probably won't find any changes. Just be aware of what does come out. Because you'll see they cover nursing homes. They will cover clinics. They will cover labs. The most recent one happened to come out and address end-stage renal disease. So just be careful which one it comes out, so you don't read anything that's unnecessary for your facility. Just as an idea about what one happens to look like. And the focus for today for acutes is here in discharge planning. And for critical access hospitals, this is yours. And on critical, again, yours is in red lettering, because that's the last date they made any updates. Unfortunately, they haven't made any since then. Briefly on deficiencies, I mentioned we don't want to get that notice of deficiencies. We can access the data, so if you're looking to do benchmarking or just find out what have they done in the past, what are they focused on, there's a way you can do it. It will include any type of hospital, acute, critical access hospitals, long-term care. It won't have the actual plan of correction, but you can ask for it. It is updated quarterly. The last update came out in June of this year. But to get to there, you would go to where it says provider enrollment certification site. You'll see hospitals. You'll also see rural emergencies. And for hospitals, scroll to the bottom of that page where you see the full text statement. And again, be aware, they do update this quarterly. And there are two Excel formats. One is from like 2010 to 2016, and the next one will be 2017 to current. How much data you wish to review is whichever one. But this is an example of what you will find when you do pull that up. Facility name, the address, where are they located, what was the deficiency tag and a description of what they found. If you're going to filter and sort by tag number, remember to put in the letter for the manual, so here I've got A, and the four-digit number for the tag number. If you don't do that, you will get the wrong information. On discharge planning in particular, I've got some examples of why hospitals happen to be incited. And these are all different types of hospitals, all different sizes. One, we didn't make sure the patient was admitted with home health services and happened to have been discharged with that same amount, so she had it at home. Just when she went ready to go home, they didn't make sure that that was still in place. The staff didn't update the discharge plan so that we made sure all of those discharge needs were met. They didn't ensure staff give the patient a list of available home health agencies. Now, I'm going to go through these requirements, but you can see how far down they really review and assess. Staff didn't make sure information wasn't transmitted to that home health agency so they could take care of the patient. They knew what had happened and what was required during home health. They didn't make sure an assessment and plans hadn't been revised for a patient who, sure enough, happened to get readmitted within those 30 days. They didn't make sure there was an accurate discharge medication list. That medication reconciliation, we know, and you probably heard the stories and the cases that have come out, where a patient comes in on certain medications while they're in the hospital, things happen, or for the reason for admission, those meds are revised or added to. And then we didn't go back when we're getting ready to send them home and say, okay, quit taking your Warfarin, and now we're going to switch you over to another blood thinner. They didn't give the patient the choice of provider for home health, which we are required to do. And then just another one more example, they didn't ensure discharge plan was implemented for a patient who was going to what's called a self-recovery unit. So again, there's some pretty finite issues that the surveyors happen to find. So why do I want to mention the IMPACT Act? What's the big deal behind that? Well, it happened to be called the Improving Medicare Post-Acute Care Transformation Act. Again, the acronym is IMPACT Act. They put it out because they wanted to start standardizing the information that CMS collected from the four post-acute care providers. And those include, excuse me, your long-term care, your home health, that's one of them. Then they have nursing homes, and then the long-term care hospitals. So there are, there's four of them that CMS says, okay, we're going to pay for services that are there, but we need to find out what information you have on the services and care you provide. And they did that so they can start improving the quality of care across those settings with, again, the ultimate goal to reduce those readmissions. So through this act, the idea was let's improve our discharge planning. That meant CMS, one, they had to revise their conditions of participation. And then they also are required now to review it every five years with interpretive guidelines. They're coming up on that next year. Again, the last big revision of addressing some of the discharge planning was in 2020. So they're coming due. And of course, there have been updates since the initial one in 2014. So here's just a scenario, just going to keep this one in mind, give you an idea on it. So we've got a patient, she had a total hip. She wants to know, where do I go afterwards? So how much does it cost and who has the really best outcomes? All of us want that for anybody, ourselves and our family members. So the idea was, do we discharge her home with home health? Or does she go to inpatient rehab? Does she go to a long-term care hospital or to a skilled nursing facility that also is a rehab center? So those are the four options. What do we tell this patient? So in this situation, what they were finding was, we don't have anything to compare apples to apples, to oranges to apples, whatever it happens to be, to find out what is the best way. Well, not only is it tough for us as care providers, but it made it hard for the policy makers to figure out where is the best place for this patient to go. And so that's why part of the IMPACT Act came out. I just included this in here, so you can go in and keep up on any changes that might come around. So from this IMPACT Act, there's certain standardized information that those post-acute care providers must standardize and then submit to CMS. And there's five of them, five assessments that they have to do. One is, what is this patient's functional ability? Can they walk? Can they take care of themselves? What's their cognition level? Can they talk? Can they express what their needs are? Do they have depression? Or do they have really bad dementia? Is there anything special they need? Are they on a ventilator? Are they ventilator-dependent? Dialysis? Maybe they need central line for TPN or other antibiotics. Anything underlying for their pre-existing conditions, comorbidities, whether it's diabetes or do they have a pressure ulcer? And then any other impairments such as incontinence, deafness, blindness, maybe they can't swallow well or they have difficulty swallowing. So those are the five areas that these PAC providers must do an assessment on. And in order to do that, now we have to have our hospitals and our PACs make sure that these forms that we have collect that data. So when a patient comes in, you know what you got. Where is this patient from day one in your hospital? Usually the RN is the one to do that. Now the regulations say they do it on admission, but no later than 24 hours after admission because we got to know where this patient is. We need that baseline. And keep it standardized so that it can go from setting to setting and provider to provider. That means you may need to look at what assessment instrument you are using so that this data is being collected. The key here to all of this is what are the patient's preferences and their goals when it is time for them to leave your facility? Now in addition to the assessment that the PACs have to provide or do, there's also five quality measures that they have to report on. Again, the functional status, their cognitive and any changes in both of those. In other words, can they walk when they were admitted to this PAC and now where are they now? Again, this is what the PACs have to report. What is the skin integrity? Do they have breakdown? Do they have bruising? Medication reconciliation, their falls, is there an incidence of major falls where perhaps they've sustained some significant injuries? And then of course transferring that information from the hospital to or maybe to another provider. So what you have to do as a hospital. Right now is make sure that the data that those post-acute care providers provide on their quality measures and their resources are relevant to what the patient's goals and treatment preferences are. And this is all hospital. It doesn't matter if you're a 25-bed critical access or 800-bed teaching hospital. These requirements apply across the board. And that's why you need to document in the record that you shared this information with the patient. Because overall, this is what they're going to need to know once they go home. For criticals, again, what you have to do is you have to provide the data for those in their area. You serve a more remote area where they don't have access to some of this information. Maybe they want to go to a SNP that's close to a family member so that the family member could come and visit or maybe start taking care of them or participate in the care with the goal for the next levels to go live with them after they leave the SNF. We should help the patient as a critical access choose that PAC provider. We of course can't make that decision unilaterally. That also applies to acutes. And really focus on their care. Involve the patient where you can in making these decisions. What I mean you can if you happen to have that incapacitated patient. As a facility, you answer their questions. You can add to it. You're not required to have the nitty-gritty on what the terms of coverage are. You're not required to have that as a critical access hospital in particular. If you know something's not right for them, you can say, okay, we're aware of that one. Here's one that really focuses on your conditions. It might be about 10 miles away from your daughter, 10 miles more, but they really focus on getting patients back on their feet and home and out of there. We always, of course, have to take credit for what we've done. That means documentation. All interactions, who was there, the patient, the family, when did this occur. And include in there if you want, you can provide insurance specifics on what their insurance would cover, maybe out-of-pocket costs. This is crucial when you have those Medicare and or Medicaid patients who do require that. The revised requirements don't prohibit you from doing this if you know it. That's why, again, you're not required, but if you know it and you want to help the patient, great. There is another way to do it that is called the Compare Site. CMS put this together, and it will help patients and their families select that post-hospital provider. In December, they streamlined eight original of those tools that they have to put together, and now they include nursing homes, hospitals. It's all in one site. It's really nice because it helps families identify where can we send my family member, where can I go if it's me. And I really like it because I've had a couple family members who they've had to have some long-term care. They had some pretty catastrophic injuries, and where they were looking to go near their home had some pretty significant concerns with their quality measures. And so, working with his wife, we were able to find one. It's a little further away than they wanted to be, but just being there and visiting them, he's really made great strides, and so that's why it was very beneficial to have. Again, you've got hospitals, and it tells you how far it is from where you live, what are the stars. Now, be aware this has patient surveys, too, in addition to the overall rating that they receive. And again, there's also specific data they provide, whether it's urinary tract infections, CLABSIs, falls. It's a really good site, and it's nice that you as health care providers will have some of this background because if I gave this information to, say, my mom, she would never know what to look at. She wouldn't know what a CLABSI is, so that's why it helps with you as the provider. Perhaps you can help translate some of that information. And then again, of course, you have the hospitals. Overall rating. This one I'm familiar with. It's near where I live, as opposed to one that's a little further away. You know, you start looking at that, and it really digs in. So this is one you may want to have the patients and their families, hey, pull it up and start reading this stuff so you get a feel for what's out there. Now if the patient or family decide, I don't care what you say, I don't care what the ratings are, I want to go there, okay, just document it and start working to get it done. Now we're going to go into the actual conditions of participation. Lindsay mentioned we do have a few polling questions and so I'm going to have her pull up this question and get us started. Perfect. Excuse me. I'm actually going to read this first part to you and then I will post the actual question here on the screen for you to answer. This question says, Dexter hospital recently experienced several readmissions from the orthopedic floor, infections and falls. The risk manager reviewed all records and found discharge planning had been started but not completed before patient discharge. Staff member out. Will Dexter be cited? And your options here, yes or no, the absence was unavoidable. And I'll put that up here on the screen for you. So you should see those options now. And while you're taking a moment to put in your answer here, for those of you who have recently joined us and missed the opening comments, if you do have any questions for Laura as we go throughout today's presentation, if you'll go ahead and be typing those into the Q&A option down there at the bottom of your Zoom window, or for some reason you don't see that option, you can of course type your question there into the chat so we can make sure to address your questions regarding the material as we kind of pause through these polling questions throughout the presentation as well. Okay, looks like we've gotten a pretty resounding response here, Laura. Okay, it looks like Dexter's going down. And you're absolutely correct. Yes, Dexter will most likely be cited on this. Absenteeism is not going to be a valid reason for not getting this done. But I do want to do something right at the beginning. So when you're looking at this new manual, it starts at Tag 799. Now I'm in Appendix A, by the way. I'll get to criticals as we go along. But it starts in Appendix Tag 799 through 830, and it covers all the standards. Now the new tag numbers will have the new standards, but they won't have interpretive guidelines or survey procedures. Now I've listed out, as you can see, all these new tag numbers. The previous tag numbers, of which there are three, they're still there. They have been modified with new standards, but no guidelines, no survey procedures. And some of these new tag numbers overlap and repeat the exact same requirement from the previous tag numbers. So what I have done is on these slides, I have put in the new tag number, but also you will see a slash with the old tag number. Just be aware, if you're reading through this, don't pull your hair out, but it is a repeat. You are not imagining. Now CMS did explain to me, because I emailed them, and I asked them, I said, hey, what's going on here? It's extremely confusing. They said the new manual will clear up any duplication. That was last September. We're coming up on almost a year. Still has not happened. So I've tried to put these things in an order. That are not repetitive and hopefully make sense and work for you. So let's start with the first one. You have to have a discharge planning process. You have to have a way to do this that focuses on what the patient wants to have happen, or it's their goals, and where they need to have this occur, the treatment preferences. So where they go, it may depend on what do they need done. You know, if they want to go to one that has absolutely hardly any dialysis or any way to provide dialysis, that's not the place for them to go. And also, what is their support network? And that means who else is around to help with them. Let's say they go home. Is there a family member or friend who can help them with those visits, maybe getting over there, make sure they get food. And again, this is what the patient and their caregiver, if they have one, what are their treatment preferences and goals for that care? Now, the support person can be different names, caregiver, support person, family. They're used interchangeably throughout this regulation. They understand, CMS understands, not everybody has that luxury of a caregiver. But if you know of someone who's around, again, could be a neighbor to take them to trips or to their doctor's appointments, take them into PT, something about that support person, make sure that is documented so that we're aware of it when we start doing this discharge planning. Joint Commission calls them patient advocate. CMS gives them these three names. It's the same thing. That's what it is. So that's what we have to do. We have to include this person. If there is one that they have identified in our discharge planning process for when the patient leaves you, ask them who takes care of them or who do they plan on taking care of when they go home. And studies show that involving this person in this process helps lower the admissions, because they remember, no, remember they said you weren't supposed to go up and down the steps. Remember, they said you're not to carry over 20 pounds. It's a good reminder for them and can also help them remind them, you have an appointment today with your doctor. So the Journal of American Geriatrics said we can reduce them by a quarter when informed caregivers are really brought into the discharge planning. Some of you have listened to the previous programs know that I talk about a blue box, and a blue box is just that. It's a part of the manual that's in a blue box, and it has really good information. You aren't cited on the information in there if you don't follow it, but there's some good also resources in these blue boxes. And what they say in this one in particular is work with your community-based organizations to help with these transitions of care, and that way you can also know what's out there. Do you have a good home health in your area? Do they service a particular area? The Veterans Administration, their Administration for Community Living, they work to help get access to these long-term care services like Aging and Disability Resource, Area Agency on Aging, Centers for Independent Living. Those are just some of the examples that CMS has identified. So again, that's an example of what that blue box would look like. And so again, working with those really helps your discharge planning process. On forms and who to include in planning, I combined this one together. Now you're not required to have a specific way or piece of paper to communicate. This is the patient care information, their health care information, and like, okay, what happened to them during their stay? You don't have to have a specific form. What you do need to do, though, is send that information to where they end up going, that receiving facility upon discharge. They won't, again, also CMS won't say which staff has to be involved in the planning. You decide who's good for that, who's the appropriate person based upon their needs. It could be PT and OT only, or maybe you want to have dietary involved, or maybe you want to have psychiatry, counseling involved. Usually your case manager makes that decision on who's going to be doing that. Policies, procedure, they have to spell out what determines what is a qualified staff person and who will be involved. I briefly mentioned incapacitated person. It could be unconscious or someone who has such dementia, Alzheimer's, that they are incapable of making their own personal decisions. So the support person, they're the ones who make the decision, especially about visitors. And they can, again, write down questions. They help support the person, give them instructions. They can ask for help when the patient won't do it. For example, I have a couple elderly sisters, and one in particular is just stubborn as a brick wall. And when she happened to have some surgery a while ago, she would not ask for pain medicine because she felt, no, I'm fine, while her daughter happened to be her support person and her personal representative. Now, she was cognizant. My sister was not, didn't have any issue with that. She was just, again, just very stubborn. Well, that pain interfered with her ability to get up and walk around like we want them to do as soon as possible so we could increase her recovery. And so it was my niece's responsibility and what she was very good at doing was speaking up and say, mom, you're in pain. Let's get it cut down so you can do this. And so by doing so, Carrie was able to communicate with the nurses. She won't say it, but I know she's in big pain. Can we give her something to ease it down? And it did. I really felt having her there helped improve her recovery time and decreased it actually. So the discharge plan overall has to be consistent with what the patient wants. What are their goals? Where do they want to end up so that it is an effective transition from that acute care to post-acute care? And it usually starts when they're first admitted. So what can the patient do? When they walk in or are rolled in, whichever it happens to be, you want to start obsessing that patient and see, can they walk? Can they bathe themselves? Can they fix their own meals? Because what we're trying to do is say, is there any gap in there now that could lead to a preventable readmission? Now, there is a predictive model that has been done that helps to identify who is at risk for readmission. And if there is an increased risk through this predictive modeling, then we may need a more detailed plan, callbacks, home health visits, something more than above what normally we would have expected. Boost better outcomes for older adults through safe transition. The Society of Hospital Medicine put this together. Great tool. You can download it. I have it in the appendix for you how to get that. There's a chart on who's at risk on having an adverse event that can lead to that preventable readmission. So for example, you've got a patient who has cancer and multiple, multiple medications, including pain medicine. Well, does that make them lightheaded? Does it make them weak in their legs? History of depression where they just kind of go back to bed and stay there and they don't get up and move around. Poor health literacy. There's another indicator. They don't have that support system to help them get around, make those appointments, maybe go buy groceries. And then just our routine comorbidities. COPD where they're just too winded to do things. Liver or renal failure, again, where we have fatigue and exhaustion. We know there's many evidence-based studies that talk about factors that increase the risk for readmissions. And then techniques. They include in there, how do we reduce them? So you've got a patient on high-risk meds. Maybe it's beneficial to have a pharmacist go through those meds. And in fact, we had done that when I was in law school, we were, we would go in and represent patients who couldn't afford to have their own attorney. And we had a couple of nursing home patients. And one of our nursing home patients, fortunately there was a pharmacist who was in the class ahead of me and him and I worked on this case. And he found that she's taking multiple meds of the same class. No one ever did that reconciliation. And so he was able to work with the physicians and cut them back. And sure enough, our patient who went from being almost abundant, start to wake up and participate in care. Maybe they need home health smart boxes for those who are on high-risk meds. So number one, they don't forget to take them or they don't double dose themselves. You know, it has morning, afternoon, and evening. High-risk patient, we send them to rehab for a week before they go home, make sure they can get up and down. They can walk to and from the bathroom. Maybe they have a dietician come in and talk about, you know, we need to boost your calorie intake and really make it good calories as opposed to all those chocolates that you've been eating. Let's get you some good calories. So we get that protein and those nutrients. Have the staff column 24 hours after. Did you get your prescriptions refilled? Did you get them filled? Maybe that's done before they even go home. And then go back over the discharge instructions. How's that wound care going for you? And then making that appointment post-op or, excuse me, before the discharge because that will help save them time. And then maybe a reminder. Now don't forget you have your doctor's appointment tomorrow morning. So here's, I know it's pretty quick, but here's question number two. Lindsey, will you put that up please? I sure will. Okay, let me go ahead and get this one up here on your screen. Okay, this one should now be up for you all. That says our discharge planning process. You can check all that apply to your organization here. Starts when the patient is admitted. Includes only patients from long-term care facilities. Includes all patient identified as at risk for complications. Includes inpatients, ED and observation patients and outpatients. Includes only patients over a certain age or possibly only includes COVID-19 patients. And it looks like we had, I think one question come in Laura. Okay. And I think, I believe this question came in from you. So correct me if I'm wrong here, but I think this goes back to the previous question or the scenario that was up that said, would this be cited unless a trend is shown or does typically one fall equal a citation? It depends on the severity and I'm trying to, okay that happened to do with the fall. It wasn't so much that they got cited on the fall. It was a discharge planning process that hadn't been done. And so in answer to your question, it could have been both because yes, we had a fall, but that could have been avoided had we done the discharge planning. That was the key there that they hadn't done it. Nobody had stepped up. They realized, yeah, this person's out and it wasn't, okay, they were out sick for a day. They were out for a while and they hadn't made arrangements to have that process covered while that person was away. So no, it wasn't just the one individual fall. It was a trend, but they knew through that trend, the discharge planning process hadn't been completed. I hope that answers the question for them. Yep. She said, absolutely. Great. Perfect. Go ahead in this poll and share those results here. All right. Yeah. I'll include that. Okay, good. Okay. And that was just informational only. So I've got the tag numbers in the upper right-hand corners. You will again see some that have two tag numbers because they're repetitive. So you have to have a process that starts right early once a patient comes in to identify patients who are going to have problems, adverse outcomes when they're discharged, if we are not doing that discharge planning. And that means we have to do an evaluation on those we've identified. Now, not only do you do it by those who have identified it, but it could be because the patient, their representative, or their physician has said, we need an evaluation done. So here's some examples. Patient comes into ED, high risk of COPD. That's one person. Yep. You want to make sure you're doing some discharge planning because you want to make sure, how are they doing at home? What's their respiratory care at home? Do they have their supplemental oxygen set up? Is that all taken care of? Those who come for outpatient surgery who have a lot of comorbidities and no one there to take care of them. There's a good example of like, they're going to have a problem when they get home. Especially, let's say it happens to be in some type of an orthopedic procedure where they can't bear weight or it's painful to bear weight and yet they have to get up and go to the bathroom. You have someone who's an observation who may need equipment once they are discharged, whether it's a walker or different medications to make sure they're taking them correctly. So as far as this assessment, what we're doing is we're trying to determine who's at risk. Where do they live? Who's around them? Do they need any equipment when they go home? That could be something, again, as simple as a pair of crutches, a cane, a walker. Do they need help with food being delivered? Maybe light housekeeping so that it's clean and sanitary? Or do they need it just picked up so they don't trip and fall over? Now, a physician can make that request. And so if that's the case, not only do you have to do the assessment, but the physician can also say, I need you to put together a plan and start it in the process. So that implementation of the plan. This is one where the guidelines and procedures are still pending. They talk about it further under tag 820. Now, as far as developing the plan, what you want to start looking at is, OK, what's going on at home? And again, who is going to take care of them once they're there? Who can provide it? We had a patient who lived in a remote area, and there was no home health agency in that area. So we were trying to scramble to find out, how are we going to take care of this person? Eventually, they did end up going to what's called respite care. We found a location for that person to go to in the interim until they were stable enough to actually go home. They were done with their physical therapy and could be released. And that may mean we're reaching out to these PAC providers to see, where are you? And can you come take care of them? Also, re-evaluate the patient. See if anything's changed so that maybe we need to revise that discharge plan. So again, here's a 90-year-old. She lived alone, came in for pneumonia. Well, while they were there, unfortunately, got a stage two decubitus. Now they're not going to be able to go home. So we need to re-evaluate that patient to see what's the next step. Is it home health, or is it a sniff? You also have to look at the process itself on a regular basis. And this must be ongoing. And do a review of what you've done, let's say, in the past 30 days or six months. Look at the sampling of the plans that you have completed. Of course, do those who were readmitted within 30 days, did something get missed? Or could we have done it better? Or maybe it's just one of those things. Just make sure again that the plans we are doing are responding to those needs. So as far as suggestions, have a process in place. How often are you going to look at them? What type of cases are you going to review? Have a list of questions so that who's ever doing this review, if you're not doing or you're fortunate to have a couple people helping you with it, they know what to look for. So we've got that consistency. Then if you want to start graphing it out, then you've got consistent information. You're not all over the board. CMS recommends you do open and close files. Open are those who you've admitted you're just waiting now for their surgery or their stabilization before they go home. So you want to look at those also. On an acute hospital, you've got a few more requirements than what a critical access hospital does. So when you're getting ready to give this information to a patient on their post-care providers. For an acute hospital, you have to help the patient. And for patient, I'm going to use that collectively to mean family and representative. You have to help them in selecting that provider. And you have to use and share the data for those four providers. I've got them listed there, home health, SNF, inpatient rehab, or long-term care. You have to give them the information and share it on their data quality measures, their resource use, and then make sure it is relevant and applicable to them. Again, we want to have the information that applies to what the patient is going to need. So here's just an example. Maybe it's close to their home, or they have good ratings on the Compare site. Maybe the patient's physician goes there, and that's where the patient wants to go. Or they're advertised as a rehab that really focuses on that patient's surgery. Again, reduced length of stay. They're in there for two weeks and home. Where another one, they might have had to stay for a month. That's one thing an acute hospital must do. You have to really share that data and help them select it. Of course, our evaluation has to be done timely. And that this way, we make sure arrangements are made so there's no unnecessary delays. You don't want to wait until, hey, you're going home this afternoon, and nobody's contacted the home health agency. Or maybe we know that they're admitted Friday, you've got a weekend holiday, and that when it does come time for them to go, they're ready to, everything's set up. Now, this was repeated. This is one you see in the upper corner, 805 and 810. This is repeated in tag 810 with the interpretive guidelines. And the interpretive guidelines mention that if you are using that team approach, meaning there's more than one service in your hospital that's doing this, you have to have a way so you're collaborating with this information. So it is timely and they're done in time. So I'm coming in, I am having a total hip. I'm going to need PT at some point in time. I can't go home. Well, PT, there needs to be a communication between the nurses and PT to make sure, okay, this is what they need, and here's the best place to go, and what they have to have done while they're at the SNF. Now, on this one, the discharge planning evaluation, again, this is repeated. This covers the requirements in the new tag number again, 800. This sounds familiar because it is. So we do an evaluation on those who identified are going to have problems when they go home. And again, the three ways, the patient, the representative, or the physician. Now, the evaluation, again, can be done by the patient. If it's the representative, you might want to include that statement in their rights that you give to the patient. You know, you have a right to have your representative present during discharge planning and evaluation. And please document it in the record when these folks who are doing the arrangements for them come in to visit with them. There have been, CMS is starting to look at some of those, says, okay, when was social services, or the person doing it, when did they come in? Because I'm not seeing documentation, or heaven forbid it was after the fact, meaning patient's gone home, and then it's documented. And again, the physician can request this evaluation. Just make sure they know what to do and how to do that. They may have to write an order for it to occur. Now, unless you have a way or a policy to develop that evaluation, then you have to, again, have a process to notify the patient, hey, you can request a discharge evaluation plan be done. Now, this is different from a screening process. This here, it's a more detailed review of what they need, and it identifies areas that have to be addressed in the plan screening process. That's very short, sweet, and to the point. Your evaluation goes into more detail. What is the likelihood they're going to need a post-care provider? They can do it themselves. And are they available? Can they take care of themselves? The caveat, again, this is repeated in subsequent tag numbers. It references different code section numbers, and I bring it up because the interpretive guidelines and survey procedures can be very confusing. But just keep in mind that we have to do an evaluation, and we have to identify those patients who are going to need some help. And then if it does require planning, get started early so you don't have to wait till the last minute. We need to know what are the likely needs they will have to happen and have occur. Is it going to be physical therapy? Is it going to be cardiac rehab? Maybe hospice? Or some non-care, non-health-related services, just to make sure they're available to the patient. It doesn't help when you set this wonderful home health up, and they say, oh, we don't service that area. Then you're back to square one. Non-health, they do talk about that really, they're there to keep the patient in their community, whether it's modification to the home, just coming in and cleaning, doing shopping, meals on wheels. In some of the larger metropolitan areas, some of the grocery stores will actually deliver the groceries to these folks so they don't have to have someone else, a family member do it. If that's available and they can get it covered, that's a huge help for these folks so they have the food that they need. If you have a patient who comes in from another facility, a facility reference, the interpretive guidelines in 806 do talk about that, where they're coming in, say, from a nursing home. You have to ask and evaluate, can that facility take the patient back? So what does that mean? There has to be some communication between you and that facility to find out, do you have the capabilities and the physicians, the providers, et cetera, to take care of that patient once they come back to you? So that means for an acute hospital, you have to know what are their capabilities and capacities for those providers. And the state Medicaid home community-based services, they can play a major role for you. Just again, you have to determine, are they available or is there a substitute that can be utilized for this individual? You might wanna discuss the ability to pay for those out-of-pocket costs. Give them a heads up on it, especially with your Medicaid, what is not covered. You don't have to know the nitty gritty of it. They just, you just have to have some knowledge. That's why whoever your discharge planner is, that's really their responsibilities. And the blue box does have the references for you. And these are directed, some of these are directed for the patient, like AHRQ, taking care of my cell. Those are items that are really directed to a person themselves. Then we have to decide, can the patient do it themselves? Is their home environment set up in such a way that it's safe for them to go to? It's their bedroom and their bathroom, maybe their kitchen on the same level, or do they have to go up some really narrow steps in order to get from their sleeping quarters down to their living quarters? The idea here is again, getting them back to where they were prior to admission. Do they need special equipment? Is it available? Who's going to provide those services to them? So the medical record, the discharge planning evaluation must be in the medical record. And what did you find from that? And that you, yes, discussed it with the patient, I would say, and the representative, if you have that opportunity. And in other words, they're available and they have one. Tag 811, they talk about the documentation between the patient and or the representative if those folks don't like your results from your assessment. So you've done your evaluation and you say, yeah, you can do A, B, C, D, okay? You've talked to them and they go, oh no, I can't do that at home. You need to document that, that they've rejected that assessment because we have to use that in putting together an appropriate plan. Are they going to go to a facility? Okay, then we have to communicate with the facility. This is what this person's going to need. So here we have already our third question. Great, Lindsey. Okay, I'm going to read this first part to you all and then I'll put the question up for you to respond to. So this says, busy hospital has quick turnover in staff with short patient stays, an average of two days. Patient A is admitted for RSV and generalized weakness. Nursing assessment was completed on day two, which showed a longer stay and post-discharge care was indicated. The physician ordered a discharge plan be completed and started. At the time of the order, there was no discharge planner on staff. Now what? And then I'll put this question up for you to select your response. So the first one says, discharge the patient without a plan. Assign an RN to implement what can be done. Keep the patient until appropriate staff is available or possibly any other suggestions. And if you do have some other suggestions, I would encourage you to type those into the chat and we'll make sure to read those out for everyone. And Laura, there are a couple of questions, I think. Okay. I'm gonna scroll back up here and make sure I'm reading the most recent one. This first question asks, so what happens when there is no support person? I'm not sure. Again, if there isn't one, okay. That's where maybe planning needs to be a little bit more expanded, I guess is a good word. How are you going to do this when you don't have that luxury of someone to help take care of you? Like I said, with the one, respite care was wonderful. They could go there. They didn't need that one-to-one care, like say in a long-term care hospital or a SNF or expanded care, but somebody was around just to kind of help them. Otherwise they were up around doing their own thing. And also check with your area agency on aging. That's a mouthful for me. To see if they know of another resources. Maybe there is one of the religious organizations that have volunteers who can come in and just check on them, see how things are happening. But yeah, not everybody has a support person or a representative to go with them. Other than that, I would leave it to the attendees to see if they have any suggestions for the person. Yeah, absolutely. So in this next question is kind of a combination of a comment and a question here. It says, we struggle to find home health for patients with certain managed MCR plans due to reimbursement rates, which prolongs length of stay. And it's frustrating that we cannot get patients what they need when they do get home. We usually have to arrange outpatient services, which does not provide, let's see, the same care or assessment of home health. How does CMS look at that scenario? I think if you've got to look at what you can do and sounds like your documentation is pretty good, that you know this is what we have done and what we can't get done. We just have to do the best you can, even though you do sometimes some of the best planning and get it implemented, they still could come back. But again, that's what CMS is looking for. You've done what you can. We can't prevent every issue that comes up with the patient, but as long as we've done what the code says we're required to do, I think you're meeting your expectations. But they have to see the documentation of what you've done and what you found out. Perfect. And then kind of along those lines, the next question is, what do you suggest you do when services are limited in your community? Yeah, that's again, some of the areas I know a lot of the rural areas that they have. The sad thing was we had one where they, the hospital didn't do as well as they could have. They found two home health agencies. One didn't service the area and the other didn't happen to take the insurance that the person had. So they just kind of says, well, not a problem anymore. As opposed to doing a little bit more research to find out what's in the area through the council on aging and the state to see who could come in. And that's where they happened to find temporary housing near the daughter for this patient. And it was for adult care of all things and it was a very small community, but it did help. The council on aging was able to identify that one for them. So again, yeah, it's tough when, and especially when they're closing because of payment reimbursement issues. CMS unfortunately doesn't give us the benefit of that. Again, if you've done what you can and it's practicable, reasonable, I think you've done what you can. And this question is similar, I'm sure to your response just now that asks what happens when a family reports that they cannot provide care for the patient and also report that they cannot pay out of pocket or cover a co-pay if the patient's out of the Medicare fully funded days? Check with your state Medicaid program to see if there's anything available for the patient as opposed to the family having to provide the funding. That would be the next step if it's not Medicare check with the state Medicaid office. Any suggestions when the only nursing homes that are accepting a patient are the ones with poor quality and the patient's family does not approve and will not reconsider a home discharge plan? Yeah, yeah. Okay, so that's two questions. One, if it's a bad one, okay, then yeah, we may need to go outside of their preferred location and document why we had to go outside of there. It's for their safety, you know? If they say, yeah, that's it, that's where we have to go. As long as it's reasonable, we document why they reject it. But you're not a long-term care hospital either. So that's why, if you can show this is reasonable, it's practicable, they can take the patient and it's safe, then that's what needs to occur. You are taking steps to help them. And then the second one I'm trying to remember. And the patient's family does not approve and will not reconsider a home discharge plan. Okay, again, the best thing to do is we've just got to work with the family, say they can't stay here. It's time for them to go home. Medicare will not pay for it or whatever it happens to. And I don't want to say that's what you all fall back on. So here's where it is. And it's time for them to go home. And this is the plan. What would you like to see modified or changed? Well, we want them to stay here. And it's like, that's not practical. That's not reasonable. And again, they're not covered. How do you want to handle that? No, they want to pay out of pocket, but I would start looking around for another one that can take them. And why don't they like the discharge plan? Because sometimes they may not agree with it, but it's what's in the patient's best interest too. Absolutely, I think this is the last question here that says our rural facility is in an area that is very close to the state line where there is a larger city. Many patients utilize primary care physicians across the state line. And we often run into an issue with having home care follow a patient due to having an out-of-state primary care physician. Are there any suggestions for this? No, that would have to be between the home health and the physician. I'm surprised they're having an issue with the home health. Is it just because of the physician where they're writing the orders? I would be surprised why they would have an issue other than licensure. It could be the physician is licensed in the state where they are located. So I'd be curious, that's a very interesting issue that has come up because I know like nursing, nurse practitioners are a lot of the multi-state licensures and they can go across state lines just to improve care in that type of a situation. So again, the physicians also have that benefit in most states. Okay, I'm gonna go ahead and end this one and there's a couple of other suggestions here. This person says to develop an on-call discharge planning for backup and include a social worker to assist with coordination of discharge plans. Yeah. Yep, excellent, excellent suggestions. All right. So speaking of which, the person who's going to do that evaluation and or plan, it has to be either done by or under the supervision of a registered nurse or a social worker or other appropriately qualified person. On this particular tag number 809, they don't tell you what those are. They have to wait, you make you wait until 818, which again, I'll cover here in a minute. The state law will govern the qualifications for what the RN or social worker must have to do this discharge evaluation and plan. Your policies though and procedures specify the qualification for the others. So here's some qualifications to consider. Have they done this in the past? Have they been doing it? What do they know about clinical and social factors? So in other words, does this person who's doing understand the mechanisms behind the surgery the patient had or the illness that that patient had and how that will impact them once they get home? Social factors, same thing. Who's around to take care of them? Are they safe to take care of them? You have, let's say you have a mom who's had her third C-section done and the only ones at home happen to be the little ones at home. Who's gonna take care of them while they're there? Help them take care of them. What resources? Does this person know what are the community resources? How are their assessment skills? Can they identify potential issues in doing that assessment for the patient? But it doesn't matter who does it. They must have clinical, social, some insurance or financial background and enough physical factors that they can assess accurately or at least to the best possible measure what those post-discharge needs are going to be. So this is some of the factors you wanna consider in your hospital policy and procedure. They move next to communication of this information of what happened with the patient. So you have to send all necessary information on that patient to where they end up going as applicable. Now, if they're going home, of course you wouldn't send it to them, but you may wanna send it to their physician. Hey, this is what happened during their recovery and their surgery. Or you send it to one of the PACs, somebody who's responsible for that follow-up or ancillary care. So back in June of last year, 2023, a memo came out and it talked about discharge planning. And it reiterated that hospitals, you have to have an effective discharge planning process to again, focus on the goals and treatment preferences and include the patient and their caregiver as active partners in that planning. So this memo said, you know what? We found that there was all information that we need to collect and send along as far as what was their course of treatment, what are their goals and send them along. This memo said, there's a lot of importance that they're putting behind getting these PAC providers enough information so we stop these readmissions or at least decrease them, or we try to prevent those adverse events. And they found that when this information isn't there, well, these PACs really can't take care of the patient. Again, they're sent home to a home or back to home and there's no walker, there's no bedside commode for them. They're not equipped, the people who were there aren't equipped to take care of them. That person who said, you know, we can't take care of this. We don't want them discharged yet. Well, why is that? Because, well, we all work and there's no one there to stay with our family members. And they did include in the memo state agencies and accrediting organizations be on the alert for these issues that keep coming up. Make sure that they are discharged in a compliant and safe manner. They did, of course, say we have the discretion to put together our own policy and procedures for meeting these requirements. In this memo, they identified six areas of concern. Some of it was missing and some was just downright wrong in what they were finding. Medications, durable medical equipment, skin conditions such as tears and decubitus. There was no communication with the caregivers or PACs after the fact. Patients who had SUDs, substance use disorders, behavioral health illnesses, or complex behavioral needs, those weren't addressed or weren't addressed right. And then we didn't do that overall preferences and goals for care. So that was the memo that came out. I have it in the appendix for you. So if you're looking to develop your policy and procedures, you might want to kind of buzz through that one real quick. But those were the six major areas. On PAC services, again, it's covered in these two, if they are discharged home with home health, or if they go into one of the other skilled areas, you must include in your discharge planning a list of those within the community that are available to the patient. There's a couple requirements. These four PACs must participate in Medicare. In the area where the person resides or area that may be going outside there that the patient wants to go to, in home health, they have to specifically request to be a part of that list. It's not automatic. But again, they must accept Medicare and Medicaid payments. We have to give it to the patient for when we have to do this, when such care is required. Now if they're in a managed care organization, you have to tell the patient. We have to verify with them which providers are in network, share it with the patient and their representative, and document that you gave them to the list, either to the patient, their representative. Again, that's for those who are in those managed care organizations. Otherwise, the patient can choose who they want to go to after the fact. Respect their goals. You can ask them, okay, yes, we know this provider and they're good, they're okay. Here's one that really meets your needs. You don't want to give out too much bad information on them. You just want to give them maybe a better alternative. And of course, we can't limit qualified providers. We can't specify providers. They're all, patient has a right to choose. One thing we do have to do is disclose if we have a financial interest in a particular post care provider, specifically home health and SNFs. And these are the ones that we normally refer patients to. Again, if you have a financial interest, the surveyors, they are told to assess compliance with that freedom of choice requirement. As far as initial implementation of the plan, if it is needed, then of course we have to work with the patient, their family, to prepare them for when they go home. In other words, you may need to arrange for those long-term care hospitals or hospice referrals. You have to make sure that there's follow-up with their providers, whether it's PT or OT or their physician, and the suppliers of that medical equipment, that it's there and it will be on site when the patient shows up. If you can get it there a day early, if that's permissible, boy, that's a benefit because then they can start to see, okay, how does it maneuver within our house? And can they get to and from? Is there a trip hazard, like a gap between one floor to the next that we just have to be aware of? Other things to provide, instructions on post-discharge options. What do they expect at discharge? Who's going to come visit them? Training on how to do their own care, and that may be a see one, do one, teach one type item. Okay, patient, I'm going to show you and your family how to do this, or I'm going to show the family how to change your dressing, and then they're going to do a return demonstration to me, and then family, you're going to teach me how to change this dressing. Talk me through it. How would you do it? Because that's a good way to reiterate that information, and then give them information. What happens if something doesn't go like you wanted it to? Maybe there's a problem. Maybe that they're starting to get a fever. Who do they call? Just saying, just return to ED, CMS does not find that acceptable. They have to have somebody they can call to say, I'm having this problem. What do I do? And it may be they're to call their physician, okay? Or maybe they do call that discharge planner to find out, hey, I can't get my equipment from this provider, this DME provider. Who do I reach out to, or can you help me get it in time? And of course, the other documentation, that it includes arrangements for the plan, that you got it going, training, what materials did you give to them? The blue box does have additional actions that we can help in transition. I've already mentioned scheduling that follow-up appointment or getting their prescriptions done ahead of time, which is great. The other one, again, they mentioned here is that phone call after the fact. So, 24 hours might be a little short, because they're just home and they're just trying to get settled in. 72 hours, they've had a little chance to kind of settle down, see how things go, and that newness of being home is starting to wear off. So, you may want to spread it back to three days as opposed to one. And then, of course, reassess your plan itself, the plan that you put together. Are there any changes that may affect their continuing care needs? Is it appropriate? Did they have something? Maybe it is an OBE case where they have postpartum psychosis or postpartum depression. Now, that's really going to change your plan at that point. Re-evaluate the patient. Maybe they do need to stay. Maybe there is something that came up that it's not time for them to go home. And then, reassess their condition regularly. CMS won't tell you how often to do that. Really, you use your clinical skills to make that determination. Here's an example. We've got a patient coming in Monday, ventral hernia repair with a hysterectomy. Ideas are going to go home Wednesday morning, Tuesday. Sure enough, this patient gets chest pain, has a PE diagnosed. Well, we no longer are going to send this patient home Wednesday, so we have to re-evaluate that plan and start over. Re-evaluate and the representative, include them in that list. Make sure, again, that the home health or SNFs are available. Make sure they participate in Medicare. And if they're in a managed care, indicate the availability of who has that contract with that MCO and document that you gave that list to them. Again, we have the freedom of choice. Tell the patient. You can choose your own post-care provider. Usually, you can put that in your list of patient rights. As a patient, you have the right to participate and or make a decision on your post-care provider. You don't specify or otherwise limit qualified, those who are on the list. And again, it's a freedom of choice, because what they're trying to do is prevent that fraud and abuse. If the issue comes up that we're not giving them freedom of choice, CMS, again, can't find you, but the Office of Inspector General can. And that's who has a responsibility to really monitor and enforce the fraud and abuse. Disclose where the patient goes after the fact. This sounds familiar, because again, CMS is repeating it. This was in TAG 817. So when we have to transfer a patient to another facility, we send everything they need to know, what happened with them, accompany the patient, or excuse me, accompany that information goes with them to that facility, how you do it, if you're going to email it, or if they have the benefit of a shared record and you can do electronically, great. But the summaries, don't delay them just because you're waiting on a physician's signature. Have them sign it and send it later if necessary, an updated copy, but make sure that information does get with them. And CMS says this is a lot. This is like their history and physical progress notes, summaries. They also mention that licensed practitioners can sign off on there as long as the state law permits that. CMS says it's okay with us as long as the state law says they can. So here's just on slide number 97, this is the list of information we want to send to the patient when they go to another facility. Why were they admitted? What happened when they were there? What was their status at discharge? Any allergies or drug reactions that occurred during their hospitalization? If you've got pending lab work that's out there, we're still waiting on their last INR to come through. Hopefully you've got that before they actually go. And please, a copy of their advance directives. This usually happens when they don't go back to their previous care facility. So that would be one where it's a new admission that they're aware. If they do go home, have information that you've got as far as care instructions. Make sure that you're giving the training to the patient or others in a way they understand. So in other words, if they don't speak English, we have to put it in their language. We have to have it translated. List of all appointments, when and where. And if they don't have a PCP, who can they go to for at least one follow-up visit? And again, this is part of that memo that came out in June of 2013. So here we go. This is a good follow-up to that one question. If a patient said, no, I'm not leaving, I'm not going there, document in the record any refusal, continue to work with them for a substitution, and make sure for that substitution we're continuing with their plan of care. But yeah, sometimes they won't agree with it. Just work with them as much as you can. I like the idea of social worker. I think that's a huge benefit. Help with the communication. Maybe a patient advocate, if you have one or however you wish to term that person, can help with that communication. And assess their discharge process on a regular basis. Again, this is the repeat of tag 803. Review of plans and make sure that it is ongoing, periodic of a sample of inpatient and outpatient, and especially those readmitted within 30 days. Now as far as the assessment, it is a huge part of your QAPI program. So you have to have a mechanism for that reassessment. CMS mentions, why don't you choose one interval to track a certain number of days? Maybe seven, they came back at seven, 15, 30, maybe longer. Do it quarterly to see, okay, how are we doing? Do we have none? Great. And then an in-depth review of that process. Do we do an appropriate reevaluation? Did we do an appropriate evaluation? What's the plan? Did it meet it? Did we get it started? These are just some of the things that you can assess for your discharge planning process. So now we're going to move over to Critical Access Hospitals for our last question, Lindsay. Okay. If I could get off mute there, I'll get this question up on the screen. We do have several questions as well, Laura. Okay. So this question says, Critical Access Hospital, our discharge planning processes are minimal and only completed on high-risk patients, include an evaluation on every patient admitted or not sure what it includes. And let me make sure there's some in the chat and the Q&A, so I'm going to make sure I'm getting all of those here. Okay. Okay. And this is a comment here that says, I recently initiated the follow-up phone calls on discharge patients and just yesterday had one that was a type one diabetic who had no refills on her insulin. I worked with providers and got her a sooner appointment with a provider to get her medications refilled. That's great, Sierra. Yes. Great, great, great job. Okay. And this question says, is the physical list required to be placed in the medical record for the patient choice of post-acute providers? Yeah. You want to give them the list and I would keep a copy in the record to show what you provided. Absolutely. Okay. If you have some quality partners, SNFs or home health, can they be listed at the top of the choice list or does it need to be an alphabetical list? Oh, that's a good one. CMS hasn't addressed that. I guess the question, what makes them the choice ones for starters? And you can tell them, we put these here because we found that they have the best responses or the best quality measures, but this list is not all exhaustive. Here's the rest of the list that's available to you. You can always make a comment. That's why they're at the top of the list. If you feel you want to avoid any spectrum or any idea of limiting, you may just want to do it alphabetical. You may want to. Otherwise, yeah, just tell them, hey, we put this at the top because we have found them to be really good at what they do. Okay. And this says, does Medicare specify a timeframe that we must give patients' representatives to choose a facility? To choose a facility? Mm-hmm. CMS does not give the timeframe for that. Definitely before discharge, but no, the regulation, they're silent on that. Okay. Is it acceptable to provide the list of patients with accepting SNFs versus all SNFs when they're making their choice regardless of payer? And the keyword here is accepted SNF facilities versus all inclusive. The thing is, if they choose one and they're not accepting the patient, what good is it? You may want to include it with an asterisk where it says accepting or not accepting new patients. That way, again, you can avoid that spectrum or that idea that you're omitting a qualified provider. Mm-hmm. Okay. We have many that will ask the patient if they can include their family in the discharge plan discussion. Sure. From a HIPAA perspective, is that necessary or possible to do? Yeah. You can, you know, so if the patient wants the family included, quick note, patient wants family present or ask patient if we can have family present. If the patient has not initiated that request or they have not designated a personal representative, then yeah, you would need to just say, do you want your family involved? Would like to have them present? Is that okay? Because we're going to be discussing your healthcare and your health status. Quick, easy, they understand it. Yeah. That's a good question because there are some cultures where they don't want the family to know. Okay. Okay. And then what do you do when facilities won't accept without signed documents? Well, you kind of got to play by their rules and then that's where they talk about having that good communication relationship with them. And I, that's a good point because there are one or two I've heard that, nope, we need the John Henry from the physician on there and it's like, okay, it delays the transfer. It does. So I would try and work with the facility just saying, we'll get it to you in a minute, but we need to get the patient transferred over. That's not, I understand why they want that signature. I get it. Okay. And I think you answered this a second ago and talking about the list here, but if you can give a list with insurance covered facilities versus all facilities, maybe that's a little bit different than those who are accepting, but. Right. Right. It does help to have the entire list and with the asterisks out of network, out of network, whatever that happens to be, then the patient would know that or the person, their representative would know. Yeah. You don't want to get them all signed up, get them ready to go and say, oh, by the way, you're out of network. Absolutely. Okay. And this, this is a final question here that says, what do we do when the doctor tells us to send to all facilities in the surrounding area and then present the patient with those that are willing to accept? Would you repeat that question for me, Lindsay? So what do we do when the doctor tells us to send, I guess, the patient information to all facilities in the surrounding area, and then just present the patient with a list of those facilities that are willing to accept that patient? I think you might have a little problem with HIPAA on that one because you're disclosing patient health information to those who don't need it. I would have an, I would probably be uncomfortable in doing that only because again, you're sending out patient care information to those who might not need it. I would maybe have a conversation without sending the information first, because you're going to know who's going to take these folks who have the ability to take these patients, capability and capacity to take them ahead of time rather than, eh, that's too much work. We don't want them. I think you've got a good idea on who's going to do that. I would, I could not promote that decision, that kind of a shotgun blast sort of a position where, hey, we're going to send it out and see what sticks on the wall. That could be a problem. Okay, and then what is a reasonable amount of time to wait for a SNF selection from patients or families in order to send referrals? I guess it's going to depend on, you know, when are they ready for discharge? Because then you have to start looking at utilization review. If they're going to be there past when they need the care and it's time to go, you set that time frame for them. It's like, you know, you've got this amount of time and we need to have you discharge. You need to be moved on to your next level of care. So I would set that, CMS is silent on that time frame. Okay, I'm going to go ahead and end this poll and share those results there. A lot of good questions. Absolutely. Well, it kind of froze on me, so it's not letting me. There it goes. it took a second, but there we go, okay. And evaluation on every, okay, good. Now this again was just, this was just a quarter minute introduction. Again, in 2020, they updated the manual for critical access. This is one where we still do not have guidelines or interpretive procedures. However, the requirements, the regulation, very similar to A with a very few differences. And I believe that the future guidelines and procedures are going to follow what we just discussed. Overall, you have to have an effective discharge process that focuses on their goals and treatment. Include the patient and their representatives to make sure we have an effective and safe transition so we don't get to see them back in our hospital that we could have prevented. It has to start early in their hospitalization. Who is likely to have consequences if we don't do this discharge planning? We have to give this, have to do that evaluation for those we so identify. And again, if the patient, the representative or the physician requests exact same language as in the acutes. Similarly, any evaluation has to be done timely so we get these arrangements done before discharge and that there's no unnecessary delays in that discharge. What's the likelihood that they're going to need them? Maybe they need non-health services such as transportation to and from appointments or perhaps they just need someone to come in and clean their house. Are they available in their area or can a patient get to them if they need it? Can they get to that physical therapy if they need it? That evaluation has to be a part of their record and that we have discussed it with the patient or their representative. And again, the patient has a right of access to their medical records. So if they don't see it in there, that could be an issue. And it also gives them a chance to read the evaluation and say, you know what, you're right, I need this. I agree with that evaluation. You don't have to go through it with them unless they ask. I would just so they're aware, hey, this is what we found as far as getting you home and safely. Then the physician can request the plan. They can request the development and initial implementation of a discharge plan. Now this is different, which talks about in 1404, who can request an evaluation. Anybody can request that evaluation, patient, rep, physician. This is the plan. Then the plan has to be a part of the records and a patient, they can get a copy if they want it. Similarly, they talk about that evaluation done by an RN or social worker or somebody who is otherwise appropriately qualified. You want to include a regular re-evaluation of your person, your patient. Are there any changes that happened that could really alter the plan? And of course, then update the plan. And I've got, again, the change, the example patient for abdominal lap, bowel resection, day three, spikes of fever, he's got a surgical site infection, back to surgery. And now they're going to be saved for a wound vac. Assess your discharge planning process regularly. That ongoing review of sample discharge plans, those readmitted within 30 days. And make sure that did we meet the patient's needs post-discharge. Now here's where it's different. From an acute, we help them select appropriate PAC provider using that data. So it's resource use, et cetera. And of course, based upon what their goals and treatments are. So we just pretty much have to give them the list. For the acutes, you really have to go through this resource data and also their quality measures. With the criticals, they do give you a little bit of leeway here. Say, here's your list of providers. You may want to though help them make sure it's the correct and an appropriate choice. Otherwise discharge them where applicable or refer them where applicable. Sending on the necessary information, the time of discharge to those that are going to be responsible for their care. So the question about sending it out to everybody, again, I think that's going to run against a HIPAA issue where those who don't need to have that information get it. And that's just what we want to try to avoid. Complete the nursing care plan updated because that will help in the evaluation and development of a plan. Evaluation, it must be part of the record. Include swing bed admission for your critical access because that's a huge benefit for you. If you have swing bed certification, determine if they're available in the area. And again, you're not prevented from using telehealth to meet discharge planning requirements for critical access. Otherwise your differences, you're not required to include in the plan a list of the four packs. You still have to help them select the appropriate one, but that list doesn't have to be part of their discharge plan as it does in the acutes. And then share the data, help them understand this is where you're going and why. So just some brief summary and follow-up information. These are some of the performance metrics on the planning process. Now, let's say you're encouraged to consider performance metrics when you're putting your process together. Reassess those metrics on your discharge planning process on a regular basis. So in other words, you've got metrics. How many patients were readmitted, let's say five days after they had an outpatient surgery of this type of surgery, maybe it was, or maybe gastric bypass surgery. How many patients came back in? Were they readmitted because we couldn't get this equipment in time for them to come home? We used to see this when we had babies who had to go home and have the billy lights. And there was a problem with getting the billy lights delivered, set up, and teaching the parents in a timely manner. And so sure enough, here are these newborns coming back in because no billy lights were available. Maybe there was a delay in turnaround times for the service, could be just a hospital bed, getting a hospital bed. You want to also pay attention to your patient satisfaction, especially with the discharge planning process. You may find some key points that you'll want to start honing in on. Nobody talked to me about the evaluation. Nobody asked for my input in where I was going to go. Now, you might want to delve deeper into that if you're starting to see a trend. The performance measures include them in QAPI. You might want to review the process every two years at a minimum. Current says ongoing. Do it on an ongoing. So however you decide, maybe you just want to do it every other month. Make it easy. AHRQ has some toolkits for you. These are free, and that may help you with starting some of your transition care programs. There's all tools and all resources. So it looks like we're going to give you back some of your time. I do want to do a quick summary with some of the takeaways for you. Always, always focus on what does the patient want? Where do they want to go? Make sure they're involved along with their person taking care of them in the planning and the evaluation. Because sometimes the caregiver will see things and know things that, of course, with the patient's consent, can disclose to you. You know, patients, oh yeah, I get around just fine. The caregiver's going, what are you talking about? You're holding onto the wall every time you walk down the hallway. That's not getting it wrong independently. Make sure the process has a way so you identify the patients who are going to need, not just, of course, we have to do the evaluation, but the plan. And make sure the physician, those who need to know, can request it. How do you do it? That can be something as simple as an order. Re-evaluate the person. See what they need. Also, for any additional services post-op or post-hospitalization, see what they need themselves. Update the plan as needed. Have those resources readily available. Make sure the process has been reviewed. And then document. That's going to be key here for what CMS is looking for. The plan, the evaluation, getting the patient involved, putting that plan into place. You gave them those resources and you did that education. And again, you have to go into great detail with the education, your patient educator, your coordinator. They pretty much know how to document this now. Patient shown this, did a repeat, and did a teaching. See one, do one, teach one. Okay, so here's my last discussion. I'll go through this and then I'll have Lindsay put up the questions. We've got an 85-year-old, lives alone, remote area, independent with ADLs, continues to drive, very active in community events. During an episode of cold and sorry weather, they decided to wash their car by hand. Now, this was in a large shed. It's okay, it's good, not a problem. Well, inside, this patient slipped on an icy area, hit his back and fell on the right side of his head on the car door handle. He was able to complete the washing. And then once he got back home or back inside the house, there was a large amount of blood on the back of his head. So he decides to get himself over to the local hospital and was admitted for further testing and evaluation. Some of you may know patients who were just like this. Well, inpatient testing showed, okay, we've got a CT, did neurochecks every four hours, very alert and oriented, had the headache that you would expect this person to have and some tenderness. The CT came back with a very small subdural hematoma, no concerns with enlarging. It looked like it had stopped bleeding. Neurochecks were normal, slight difference at his hand grip right or the left. Now, they couldn't tell if that was because of his age. He did have some arthritis in the hand. So again, they couldn't tell was that neurological based or was it just, that's him. Now, given the concerns with his decision-making and where he was living and that his next relative, his son was a good four hours away and that's a good weather. They decided we're going to admit you to swing beds until we can get you further arrangements, whether it's home health, maybe assisted living, visiting nurse, whatever it happened to be. So here's the question. This patient is adamant. I am going home, period, that's it. Now, the family can't routinely be up there to be with him because of the distance and they have jobs, they have to work and they have families. Home health wasn't available. It was available, excuse me, but very infrequent. So this may be an answer to some of the questions. So now what? Now, what do they do? Do they just say, you know what? You're incompetent. We're gonna have the family decide where you go. Social services, start planning for long-term care. Get a family meeting, get everybody in there. What's best and safe. And it could be more than one here or anything else that you could suggest for our patient. And with that, Lindsay, I'll turn it back, see if we have any additional questions or comments. Absolutely, and if you do have any other comments here in regards to some discussion question, I encourage you to type those into the chat option and we can address those. Let's see, we do have a couple of questions here. This first one asks, what do you do when APS says a patient is not safe to go home, but you can't find an accepting facility for the patient? Wow, that's a tough one. And APS doesn't have any resources, I'm sure for you. They're just there for adult protective services. That is a tough one. If you're a small hospital, is swing bed available for that individual? And then as far as accepting, there's gotta be some state agency has to have a way to identify somewhere for this patient can go. Is it they don't wanna take the patient or they can't take the patient? So that's different. Some of these facilities might run into some difficulties if they can take the patient, but they just don't want to. In other words, they've got three empty beds and because of the patient's demand on staff, it's like, well, then that's their responsibility to get the staffing. And I know that's a pie in the sky thought sometimes to try and find adequate staffing. But if you can take it, they may be required to take that patient if they have the capacity to take care of them. Otherwise, I'm afraid they'll have to look for their adult services. They're again, counsel on aging and see if they have any additional resources or help that could help. Otherwise, I'd get the state admins involved, see what they can do to help get this person into one of those care centers. Okay, and then another question, or this one asks, where do they find the AHRQ transition toolkits? Is that included in your resources? Yes, yeah. I believe it is. And once you're done with the polling, then I think I can flip through a few. I always try to include the links there for you. Again, you have to copy paste or type it in, but I always include those so you can access them quickly. Yeah, so the link to the slides is earlier in the chat. I'm actually gonna go ahead and put that in the chat here all for you in just another moment. And it is a PDF copy of the slides, of course, so you won't necessarily be able to click on the link. So as Laura mentioned, you should be able to copy and paste them into your browser. Okay, so this says, this person believed that hospitals are covered from a HIPAA standpoint to send referrals to facilities that can meet the patient's recommended LOC without their permission in order to timely secure options, of course, always being mindful of patients' preferred facilities and starting with a geographic area. And if you have a different opinion, if you might could give a little more insight to that. That's another one where, and I usually put it in there and I don't recall seeing it this time. My disclaimer, please check with your counsel on that too, because you may have a state law that enhances, that's the word I'm saying, enhances the HIPAA protection when you are sending out this information as far as what you can send, because how much information are you sharing with them? It may just be the absolute need to know. This is what we have on this patient. This is what they require in their daily care. That could be enough that it would be sufficient to, yes, sending them out to find out who can take this patient, who will take the patient. Perfect, okay, I'm gonna end this and share those results there. Great, yeah, family meeting, absolutely. We've gotta find out what we're gonna do with this one. Excuse me, no, on this one, they ended up doing exactly what the majority of you said, family meeting, getting everybody together on what's best for them. He wasn't incompetent, stubborn, but he wasn't incompetent. And just because he wasn't making a good, a smart choice, doesn't mean he's automatically incompetent. So then after further discussion, they were finally able to say, look, it's just gonna be short term, that's all it is. That's what he was worried about, that they'll put him into a nursing home and that's it, and he'll lose his farm. We're like, no, no, no, no, no, that's not the intent here. And so he did finally agree to go to one of the, what was it? It was not a long-term care hospital. It was a rehab facility. And he was able to, at times when he could, the family would come up and visit with him, take him to the farm, he could see what was going on, and then he'd come back. And that helped him understand, yes, indeed, everything's safe, you will be going home. He did end up going home, and he's back to driving again and doing just fine. They just asked him to stop washing his car in the middle of winter, take it to a car wash, they're there, that's what they do. And he did finally agree. So while we're finishing up, I do wanna just flip through some of the resources. I've got the IMPACT Act, cultural health. Don't forget that when you are doing discharge planning, remember the culturally competent. There may be some cultural issues with taking care of the elderly. Always do the teach-back tools available. Medicare Learning Network, that helps when, for you to help get some background information that Medicare has put out on patients who need to have this training done. And there, there's the AHRQ, that you can go into there and start finding those links for AHRQ. But again, AHRQ is a great resource. And normally it's, everything's free. You can tap into it easy. You may have to put your email address in because they wanna make sure where it's going. But otherwise, yeah, that's a really nice resource. And so with that, Lindsey, we'll give them back 20 minutes of their day and I'll turn it back to you. Absolutely, thank you so much, Laura. I did just post a final reminder there for you all in the chat that you're gonna receive an email tomorrow morning, but just note that it will come from educationreply at zoom.us. And so because it comes from that Zoom email, it may get caught in your spam or quarantine folders. So if you don't see that in your inbox in the morning, I would encourage you to just check those additional folders. And then if it's still not there and you would just like to go back and access the recording of today's session, you can use the same Zoom link that you used to join us for the live presentation to also access the recording. And just remember that the recording is available for 60 days from today's date. And you will just need to click on that Zoom link and type in your information for an email to come to us for approval. We do approve those requests very quickly, but we ask that you give us one business day to do that. And then again, you'll have full access to the recording for 60 days. And also included in that email tomorrow morning will be a link to the slides, but I did provide that there for you in the chat to have as a resource now as well. And of course that includes all of the additional resources that Laura just discussed with you all. And again, if there are links included in that, you will just need to copy and paste those links into your browser to get that information. And then finally, for those of you who are joining us from the Georgia Hospital Association, please pay special attention to the link to the survey that will be in that email tomorrow morning. And that is how you'll obtain any information regarding continuing education credits. And if you're joining us from a partner state hospital association, I do encourage you to reach out to your contact within your hospital association to obtain information regarding CEs that are available to you in your state as well. Okay, and just some great comments here, Laura, saying wonderful presentation and great information. Thanks so much. As always, we thank you so much. Okay, and if you do have any additional questions, you can always email us at education at gha.org. We'll be happy to get those questions over to Laura. She is wonderful about being very thorough and timely in her response. And we just appreciate her for always going above and beyond and doing that. So don't hesitate to reach out to us. We'll be happy to help in any way that we can. Thank you all so much for joining us. We look forward to having you back with us for future sessions. Thank you, Laura, as always for your time and information. I hope you have a wonderful afternoon. Thank you. Thanks everyone. Thank you, Lindsay. Bye-bye. Bye.

discharge planning

patient readmissions

Laura Dixon

risk management

patient safety

CMS

hospital improvement rule

discharge plan implementation

patient and family involvement

timely evaluation

documentation and communication

CMS guidelines

QAPI programs