Now, I would like to introduce our speaker to get us started with part three today. Dr. Tony Sesta is a founding partner of Case Management Concepts, LLC, a consulting company that assists institutions in designing, implementing, and evaluating case management departments and models, educational programs, and on-site support for leadership and staff. Dr. Sesta has been active in the research and development of case management for more than 25 years. Her research has included two funded studies measuring the effects of a case management model on congestive heart failure and fractured hip patient populations with measures of patient satisfaction, quality of life, and short and long-term clinical perceptions and outcomes. Thank you so much for being back here with us this morning, Dr. Sesta. I invite you to kick off part three for us. Thanks a lot, Lindsay. Welcome, everybody. Good morning. And before we get started, I want to wish everybody a happy case management week. I know there's a lot of festivities going on in a lot of your hospitals. I hope so anyway. Thank you for the heart there. Yeah, so congrats to all of you for all the work that you do throughout the year. Just wanted to mention that. So today, we're talking about one of, frankly, my happiest, one of the topics I enjoy talking about. And it's so interesting because when you think about discharge planning, it always sounds a little simplistic, right? It's not a big deal. But you know what? Things have gotten way more complicated, particularly now that CMS, the Centers for Medicare and Medicaid, has introduced the social drivers of health. Now, some of you may remember them as the social determinants of health, but they have now changed it to drivers, social drivers of health. So I'm trying to practice saying that so I say it right for you all. In our fifth webinar in this series, we're going to talk a bit more about those social drivers of health, but they are part of your initial assessment that you do when your patients come into the hospital, and that all relates to discharge planning. So we'll talk about what the regulatory requirements are, but also what the best practices are and how this all kind of comes together, sometimes not very easily and sometimes very, very easily. So what is a discharge plan anyway? And when we think about discharge planning, we also talk these days about transitions in care. So I'm going to touch on that, too. And to me, they're distinct and different issues. So where is the patient going to go or be transferred to when they leave your acute care facility? What types of services and what types of care will they need? Now that one's really important, and you may have heard me before talking about physical therapy driving discharge planning. And I'll probably touch on that again throughout this webinar, but as an introductory comment, I just want to say you are the discharge planner if that's one of your roles. You are the discharge planner. And yes, physical therapy should make a recommendation in terms of what clinical needs that patient will have in the next level of care. But you, as you create your discharge plan, have to think about more than just that. What other types of services or care may this patient need? And so we don't want to just blindly take what anybody is saying. We want to look at that whole person in a very comprehensive way. So we'll come back to that. What the patient and family should do at home if they're going home to support their recovery. So again, that's not what physical therapy is necessarily looking at. You're looking at, again, a more holistic approach to all the different variables related to that patient and family. Medication prescriptions and instructions on usage. Now, some of that falls under us. Some of that may fall under the staff nurse to do that education. But we can certainly reinforce the need to be compliant with taking those medications. That's one of the areas in which patients sometimes misstep when they go into the home. We have to arrange for any medical equipment or supplies. We have to now look at community resources. Now, this, while not new and something we've all done in the past, CMS is emphasizing more and more in its language. They want us to look more at the patient's psychosocial needs. Some of that is those drivers of health that we'll talk about. And what resources may that patient need to help pay for their care? So there's a bunch of different categories here. You know, it has to do with where the patient's going to go. What kind of clinical and non-clinical services will that patient need? Is the family going to be able to support them? Do they understand they have to take their meds? And so on and so forth. So lots of different pieces to this. Not just sending off some paperwork to some organization. Why is it important? Well, if we start discharge planning on day one, which is what we do in our best practices, it helps us to manage the length of stay, also to manage cost of care, which we will talk about next week when we talk about care coordination, ensuring that patients receive the right care at the right time and the right place. So this is where you start to see utilization management and discharge planning start to interface with each other, because we need to know, from a clinical review perspective, what is the right time to transition that patient? And from discharge planning, what is the right place? We want to make sure that next level of care is safe. And by that, we mean, you know, is the patient going to be able to manage in, let's say, that home environment? Do they have scatter rugs on the floor? Are they going to trip and fall? All those sorts of things. And that they meet the patient's clinical and social needs. We want to ensure that the next level of care is consistent with the patient's goals and preferences. Now, that is a mandated requirement now, and we're going to talk about that. As you do your discharge planning, you've got to make sure that you are addressing and understand the patient's goals and preferences, and that you've considered those in the discharge planning process. And then, of course, maintaining compliance. So, the rules of the road. Clever, right? We've got the road there, Lindsay. We've got the rules of the road, so let's talk about what that means. So, as we talked about last week, I touched on the conditions of participation. So, for those of you who may not have been with us last week, the Center for Medicare and Medicaid Services, CMS, as we know, has these conditions of participation for hospitals. Hospitals must comply with these conditions of participation. They must follow all the rules in these COPs in order to be reimbursed through the Medicare and Medicaid programs. And they do have two subparts that relate to us. So, last time we talked about utilization review, and today we're talking about discharge planning. We also need to understand that if, in our state, there's a state regulation that's more restrictive than the conditions of participation, then that will override. So, your state regulations that are restrictive will override the conditions of participation, and we know that every state has different requirements for certain things. Okay. So, in Section 482.43, they give us a bunch of things that highlight exactly what we have to do. So, we have to have a process, and that process has to apply to all of our patients, and we must have policies and procedures in writing. So, what I always say is case management departments should have their policy and procedure manual, and in that manual, there should be sections, and of course, one section should address discharge planning. And when you're surveyed, you know, they may ask you about that. It's also a good tool to use for orientation purposes for new staff. They also say we have to identify at an early stage of hospitalization patients that might suffer adverse consequences after discharge if there is no adequate discharge plan. So, what they're saying is they're not saying we have to start our discharge plan immediately on admission. I'm telling you, however, that that is best practice. If you look at the average national length of stay, as we did in Module 1, we saw that it's around 4.5, 4.6 days. So, if it's four days and you don't start your evaluation for discharge planning until day two or three, you're going to have a delay. So, we want to start on day one, anticipating that things may change. So, what they're also saying is we have to provide a discharge planning evaluation to all patients identified in this section, but other patients upon the patient's request, a person acting on behalf of that patient, or the request of the physician. Now, we're going to talk a bit more about this because, again, best practice is that we assess every patient. So, while CMS doesn't require that we do so, patients who manage to get admitted to hospitals today are usually pretty sick and require some kind of a discharge plan, at least an evaluation of such. They also say that an RN, a social worker, or other appropriately qualified personnel must develop or supervise development of that evaluation. So, what they're telling you there is you can train a non-RN or social worker to do this evaluation. I actually am working with a hospital right now that did exactly that. So, they also tell us what must be in the evaluation. Now, they call it an evaluation. We usually call it an assessment, but for purposes of discussion today, they are basically the same thing. So, discharge planning evaluation must include the likelihood of that patient needing post-hospital services and the availability of such services. So, these are questions, these are assessment questions that you are going to tap into. The likelihood of the patient's capacity for self-care or the possibility of the patient being cared for in the environment from which they entered the hospital. So, that should always be your first thought. Where did this patient come from and is it going to be appropriate for them to go back there? So, maybe they came from home, but they didn't do well in the home or they have a new diagnosis or surgery that's going to require a ratcheting up of that level of care. You want to do it timely, as I said, because now CMS says to avoid unnecessary delays in discharge by starting early, but again, no time frame. They kind of leave that up to us. And of course, all of your assessment information, any other activities related to discharge planning should be in the medical record and discussed with the patient. So, I actually see this as a conversation with the patient and family while you're gathering this information and then discussing the results. For example, you can say something like, I see that you came from home on this admission, but following your surgery, we think you're going to need some rehabilitation. Once you've started your rehabilitation here, we'll see what kind of rehab you'll continue to need after you leave the hospital. I know that's a simple example, but what they're wanting you to do is have that conversation with the patient and have it as early in the stay as logical. And then they tell us that the physician can request a discharge plan. So, if you determine this patient can go home and doesn't need any continuing care services, the physician may request that, and so then you must do that. You also have to implement the plan, of course, and doing a reassessment of your discharge plan is really important. It's an expectation of the conditions of participation, because patient conditions change as they progress through the hospital stay, clearly. So, if you're not reassessing and reassessing, and this is where walking rounds can be very helpful, where the team comes together to discuss the patient's progress and whether or not, you know, that discharge plan is going to be – continue to be appropriate. So, ongoing reassessments, you know, that – especially when you're starting on day one and things change. You also must prepare – they say counsel, I say teach – to prepare the patient and family members for that post-hospital care. Now, that falls under our responsibility, and looking at national numbers in terms of satisfaction with that particular one, we don't do very well. We're getting very low scores nationally in the HCAHPS on that particular last one. The patients didn't feel they were properly prepared. And the solution to that is to repeat and repeat every single day, talk to the patient every single day. So, your job is not to just have the physical therapist say this patient can go for acute rehab, you fill out some forms, and that's the end of it. This is a much different approach, much more comprehensive. And then, of course, you have to send, along with your patient, all the appropriate medical information, and that includes outpatient services, even ancillary care. You have to reassess on an ongoing basis. Your own process has to be reassessed. So, you leaders, you should at least annually be looking at it. You want to do a review of medical records to make sure that they're being done timely by the staff, that they're meeting patient needs, and I would also correlate that information to readmissions. So, I would pull some readmission charts, 30-day readmissions, and take a look to see if discharge planning had any part to play in that readmission. So, back in 2019, CMS, after teasing us for a number of years that they were going to have these gigando new discharge planning rules, they finally issued their rules in 2019 for compliance required in November. So, they said this, discharge planning is an important component of a successful transition from hospitals and post-acute care settings. Well, they had never said anything like that before. They'd never made an active comment like this. So, I thought that was encouraging because now they're starting to recognize the value and importance of discharge planning. So, a bunch of stuff in the final rule. Some of it overlapped with the rules and regs that were already in place. So, we must identify at-risk patients and provide timely discharge planning. We have to include the likelihood of the patient needing appropriate post-hospital services, but not limited to SNFs, home health, rehab, or long-term care hospitals, but also non-healthcare services. And I think we have to really think about this one a little bit better, and community-based resources. And we heard that language a little bit ago. Also, must include availability of appropriate services, as well as the patient's ability to access those services. So, yeah, the patient's going home with home care. What else does that patient need? Maybe they need to go to a day program if they're a senior. Maybe they need Meals on Wheels. This is what they're wanting us to think about, these other community-based resources. They realize that patients may prefer not to participate or refuse discharge planning, and they have the right to do that, but you must be sure you document that in the medical record so that it's clear that you attempted to provide discharge planning to the patient, but they declined. You also must help them in selecting a post-acute care provider by using and sharing patient-relevant data on quality measures and resource utilization in those areas, and we'll talk more about that. And now the choice list was updated a little bit. Before these changes in 2019, you only had to give choice lists for SNFs and home health agencies. Now they've added IRFs, acute rehab, inpatient rehab facilities, and long-term care hospitals. You don't have to give lists for anything else, but I certainly see some hospitals giving lists for hospice. I even see folks giving lists for durable medical equipment. Some of that I don't think is necessary, but okay. When you give the list, it's supposed to be modified to that patient, not just give a printout that you give everybody. The list should be specific to the geographic area where the patient would like to go, and if they don't have a preference, the geographic area of the hospital. You can do either one of those, but maybe they want to go stay with their son in another state or what have you. So that specificity should limit your choice list, so that can be difficult. You also want to pick facilities or services that can provide what the patient needs clinically and that takes their insurance plan. So there are software programs and case management software that you put in those three variables and it gives you a list specific to that patient. You have to document that you gave the list to the patient or representative. You do not have to put that whole list in the medical record, and I know some folks do because they feel it's a little bit safer. Some other things about the final rule. Now here's where they talk about the patient's treatment goals and preferences. So you have to align your discharge plan with the patient's treatment goals and preferences, and the providers to include the freedom of choice for patients or their representatives in selecting a PAC provider has to be discussed with that patient and family. You're free to use anyone you like. If you choose to pick a provider who's not in your network, for example, you will have to pay for that out of pocket, but you do have the freedom to do so. Once the patient's discharged, they have to go with all that necessary and pertinent medical information, as we said, and has to go to the appropriate post-acute care provider, and within that should be included the patient's current course of illness and treatment. These are the three new things. The goals of care, the patient's goals, and the patient's treatment preferences. You have to be very sure you've documented those three things. Some of the challenges with these new rules, one is that it may be difficult to get that quality and resource information on the CMS Compare website, and rehab and LTCHs are not even on that at this point in time. This is another reason why case management software can build lists for you with those quality indicators and resource information about that post-acute care provider right on it. Some of you may listen to Dr. Ronald Hirsch, who talks a lot about utilization in particular, but he did say this, it's not an easy process. If I search for SNF in my zip code on SNF Compare, I get a listing of 10 facilities, and each has a star rating for quality. If I select a single facility, it takes me an additional four clicks to get to the actual quality measures, but it's just a list of the measures. Not terribly helpful if we want to try to be as compliant as we would like to be. You can't say any facility is preferred by your hospital. However, you can put the list in any order you like. They don't say we have to do it in any particular order. You can certainly put your own facilities at the top, but you have to be sure you have that little asterisk that says they have a financial interest in your hospital or vice versa. CMS says the goal of all these final rules, and as you can see, they've really pulled in patients and patient choice and patient preference and conversations with patients in a way maybe that they hadn't done quite so much in the past. They're saying by doing that, you're putting the patient in the driver's seat of their care transition. So the whole goal here is to engage the patient more actively in the process, and I think that's a good thing. So part of what we just talked about dovetails with the IMPACT Act, which came out in 2016, the Improving Medicare Post-Acute Transformation Act. Not a mouthful, but this became the foundation for those final discharge planning rules and changes to the conditions of participation. So while it really focuses more on post-acute care, it does relate to the work that we do as well. So let's just take a look at it. mandates for your post-acute care providers that they collect common patient assessment data and quality measure reporting. So this was not mandated before for them, believe it or not. It requires the general acute care critical access hospitals, for those of you who are in critical access hospitals, and post-acute care providers to meet the intent of facilitating the flow of patient information, and it sets post-acute care payment rates based on the clinical characteristics of the patient rather than on the setting of care. So that's a new one. That was new and different for them. They also incorporated some standardized assessments, including some components of the care tool. If you have not seen the care tool, you can look at it online, pretty big tool. And you take all of that and you can add it into your existing assessment tool for the post-acute world. And then this will help to develop and establish publicly reported quality measures. So what they're trying to do is give us more comprehensive quality information in this act that then can be used when we have conversations with patients and families about post-acute care. Excuse me. So these quality measures, in addition to just that list, you know, the list, and then the quality info on those post-acute care providers is what we're expected to share with our patients and families. Okay. Some other rules and regulations. 2016, the Notice Act, Notice of Observation, Treatment, and Implication for Care Eligibility Act, the Notice Act. And this one does directly affect us. The other one did, too. So the purpose of the Notice Act really came as a result of a lot of complaints. Patients were complaining to organizations like AARP and others that they had no idea that they were put in observation, which is an outpatient level of care, and that their out-of-pocket risk would be higher. And these complaints led to the Notice Act in response to that. And the purpose of the Notice Act is to notify a Medicare beneficiary, and this will include your Medicare Advantage plans as well, that they are receiving observation services as an outpatient. And what they tell us in the Notice Act is you don't have to notify the patient that they're in observation until you've hit the 24-hour mark. I can tell you that I understand that logic because if a patient is in observation for less than 24 hours, they're still an outpatient, and they still may have some out-of-pocket costs, so whatever that means. Critical access hospitals are included in the Notice Act, and the Notice explains the implication of their status as an outpatient on the services that are furnished. Implications, they call it cost sharing. I call it out-of-pocket requirements. And then subsequent coverage eligibility, for example, if they're going to go to a skilled nursing facility and they need that three-day stay, three-night stay. They have to sign it, and their refusal to acknowledge receipt requires signature by the hospital staff. And, you know, the same thing that you would do for anybody who refuses to sign a particular form. Okay. Some of you may be familiar with the PASAR. It's been around since 1987, so it's not new. It's the Pre-Admission Screening and Residential Review Regulation. This is an assessment that you would use to ensure that a person with a severe mental illness or mental disability is identified and placed in the most appropriate setting to meet their needs. So you have to complete a PASAR screen for all patients discharging to a Medicaid certified nursing facility, regardless of that patient's payer. So PASAR is used fairly regularly. And then, of course, the IMM. Really, I should put another M there, Important Message from Medicare. And this is your Notification of Discharge Appeal Rights Regulation. So this is a requirement. We give this to the patient twice. We give it to them on admission or even as far out as two days of admission. And it explains the discharge and appeal rights for the Medicare beneficiaries. And this, again, would include traditional Medicare and Medicare Advantage plans. The purpose is to explain to the patient on admission that they have the right to appeal their discharge, and it has to be in writing and signed and all of that good stuff. And then within two calendar days of the day of discharge, the second important message has to be given. And they do not, do not want to see you routinely giving this to patients on the day of discharge. First of all, you're going to have patients who may appeal, and now you've added days onto the length of stay. You probably will anyway when a patient appeals. However, if you do it in enough time, it will chip away a little bit at that. In 2020, they added this further requirement that you have to explain to them what number to call for their plan if they're going to appeal. So the dreaded IMM. And the other dreaded one is the post-hospital extended care services three-day stay rule. My goodness, we've all been waiting for the three-day stay rule to go away for how many years now, but here it is. A three-day inpatient stay is mandatory for your Medicare patients that are requiring placement in a SNF after hospitalization. Now, those three days are counted as the number of days the patient is an inpatient at midnight. Observation service days do not count as part of the three days. Remember, they have to be an inpatient. Observation is outpatient, and that's just very logical. So this applies to your traditional Medicare. But the bright light here is that some Medicare Advantage plans and some commercial care plans do not require the three-day stay. And I'm going to go out on a limb and say that most do not require it. It's less expensive for them, for the patient to go more quickly. Thirty-day window after discharge for patients who were discharged from the hospital but not to the SNF. And a three-day stay is not required, and let's remember this, for acute rehab or long-term care hospital discharges. So that's something that some folks forget, you know, but that's also a good thing. We have to also, and I talked about this last week, about the fact that we have contractual agreements with managed care companies, and case management departments are oftentimes, quote, not allowed, unquote, to see the contract. So how do we know if we're being compliant with the contract if we can't see the contract? We don't need to see the whole contract, finance or your managed care department, whatever you might have. Oftentimes, you know, don't want anybody to see the financial components of the contract. We don't need to see that then. What you do need to see, however, is the utilization management portion of the contract, and if there's also elements of information about discharge planning, and usually those have to do with resources that may be provided by the payer when you're trying to access some kind of a service for your patient, and that's who you're going to reach out to. You need to understand what their take is, if you will, on all of that. You don't know that, and they tell you to go to the manual online and all of that, but you may have other specificity in your contract that's not going to be there on that generic list of information that they provide. So it is important, and I talk about it a lot for that reason. It's something, you know, has to be worked out, and it's getting better, I have to say. The more times I go to finance and ask to see the utilization review portion of the contract, more and more we're getting a sure on that one, sure you can see. So discharge planning, the past. Okay, so this is the not-so-good-old days. The patient was admitted to the hospital. Not every patient was looked at for discharge planning. I remember sitting, you know, we would have a little meeting with social work, and we would talk about, you know, does this patient need home care? It was all very loosey-goosey, I would say. The only two things that we typically thought about for discharge planning were is the patient going to a nursing home, or are they going to need home care? And that was basically it. And the paperwork was usually filled out by the social worker and signed by the nurse, which also I don't understand. Then the patient was discharged, and there was little or no follow-up. I mean, the patient went out the door. That was, in our minds, the end of our responsibility. Today we're looking at discharge planning in a different way. We want to have timely, appropriate, and complete discharge planning and transitions that are also compliant. So compliance really does drive some of this, as we just saw. So the patient is admitted with a timely and complete discharge planning assessment and a social driver of health assessment. We begin a timely post-acute care planning process, including an assessment of appropriate care providers as needed. So this is when we start, you know, talking to the patient and family about what kind of services they're going to need when they leave the hospital, working toward a list, and then getting information regarding those post-acute care providers and giving that to the patient and family and other caregivers related to that patient, and discussion regarding goals of care and preferences. Again, this is not linear. You know, you're going to go back and forth on this, of course, but you've got to make sure you do that. You've got to make sure that you document that. And then as soon as that patient is clinically ready, appropriate to go, prompt and complete handoffs to the next care providers. So the basics of discharge planning. You start on the day of admission. Again, best practice. Begin the process. You want to meet the patient on the day of admission and begin thinking about their post-discharge needs. Consider the appropriate post-hospital discharge destination. And, of course, you know that might change, and CMS recognizes that that initial discharge destination that you've selected may change. You want to identify what requirements you're going to have to fulfill for that patient to have that smooth, safe transition from acute care or from a post-acute care facility to his or her discharge destination. And here's where we start to talk more about the whole team. Discharge planning is not something you do in a silo by yourself. It requires the entire team. If you think about it, the nurse is giving her input. The physician is giving his or her input. The physical therapist is giving their input. Case management is giving their input because we have other bits of information that are going to inform that discharge destination. So everybody has a role to play, and this is, again, where walking rounds or if you don't have walking rounds, if you have stationary rounds somewhere, that this is where this conversation can take place. So it's an interdisciplinary process where everybody has input. And I can't stress that enough. And, again, that goes back to the physical therapist telling the case manager the patient's going to acute rehab and nobody thinks about it any more deeply than that. I think that's flawed, and I think that that results in a lot of potentially needed services being overlooked for that patient. So you want to complete in a timely fashion your discharge planning evaluation and identify your patient's preferences and goals of care. So, again, this is meeting the intent of the conditions of participation but making it real. So what are the must-haves, some of the must-haves, in the discharge planning process itself? You want to maintain a complete and accurate file of appropriate community-based services, supports, and facilities. So a file of community-based services is really good or where you can go to where a patient might go for counseling, where a patient might go for smoking cessation, where they might go for mental health issues, anything like that, you can keep on file. Some of my clients actually keep notebooks, but, of course, they're electronic. Coordinate discharge planning evaluation among the various disciplines responsible for patient care. Again, interdisciplinary coordination. Follow the rules and regulations related to discharge planning and ensure strategies are in place for you guys when there's a staffing emergency or some folks are not finished with perhaps their orientation or what have you. So emergency planning for those bad days, and sometimes that's every weekend, right? Some other stuff on the process. So the RN case manager or the social worker would complete the admission assessment. Depends on your model. We'll talk more about that in our fifth in the series. And complete an assessment of the social drivers of health on the day of admission, hopefully with post-acute care destination expectation identified. Seventy to 80% of the time, you're going to know pretty well what that post-discharge destination should be. And so you can document that, and if you're afraid to document that because it might change, that is okay. CMS says, we understand it may change as you continue to evaluate that patient, but you really should identify something early on. If you need to make a referral to social work, again, depending on your model, then you would do so in a timely manner also. As I said, rounds and alignment with the other stakeholders in the discharge planning process should continue every day. Nursing, physicians, PTOT, and other ancillary services relevant to that particular patient. Identify discharge barriers. That's information you can share on your interdisciplinary rounds. Those might be avoidable delays. They may be barriers in the community associated to that patient. They might be social driver issues. That's what you guys are bringing to an interdisciplinary rounding process. You have a lot to share. It might be insurance information. Maybe everybody wants the patient to go home with home care, but they don't have a home care benefit. Assess and reassess continuously and update the destination as the patient's needs change. You're going to determine which post-acute care provider the patient has selected after the patient has an opportunity to review their choices and the outcomes of those post-acute care providers in terms of quality and resource utilization. Under resources, and I don't recall if I have another slide on it, so I'll just mention, under resources they talk about staffing, particularly in SNFs and home health, what are the staffing resources, nursing in particular. They talk about what other services are available or not available in that particular place, wherever that is, that the patient might be going. So it's quality data, it's resource data as well. So you know you may need several options. There may be those patients that you really can't determine early on whether maybe they are going to go home with home care or they're going to need to go to a sub-acute level of care in a skilled nursing facility or elsewhere. So that's okay. You may have to kind of run two courses at the same time. You want to keep good communication going with your post-acute care providers and share the care plan and that patient-specific needs, including those social drivers, with the hospital but also with the post-acute team that you're going to be sending the patient to. And document, document, document all the steps, all the steps you're going through. There's a lot of work that goes into this. And if you just say no discharge plan needed, that really doesn't adequately demonstrate how much hard work and how much appropriate work and how much compliant work you put into this process. So let's just talk with a few tips here about how you can address some of these CMS issues. Develop the plan under the supervision of a registered nurse, social worker, or other qualified personnel. So again, I'm going to say 98% of the time I see a registered nurse or a social worker developing that first discharge planning assessment. But if you want to use somebody else, you can do that, but they have to be adequately educated. And I would suggest that if you choose to do that, that that person has a very solid orientation that's well-documented and that they're able to demonstrate and that you put in their file that they were able to do this adequately. You want to be consistent with that Freedom of Choice Section 1802 by not specifying or limiting qualified providers, but you must identify any provider in which the hospital has a financial interest. So the only limitations that you're going to provide to that patient are those that we discussed earlier, geographic area, requests by the patient, and then, of course, can they give the service the patient needs and do they take the patient's insurance, if that's appropriate. So these are your choice list requirements. You must, again, with this post-acute provider financial relationship with the hospital, a simple asterisk with a note at the bottom of all of your lists covers that. There are some exceptions, as I said earlier, for your Medicare Advantage plans. So if you think about it like you would think about any managed care plan, the managed care plan is going to delimit the post-acute providers available to that patient. When that patient signs up with that plan, in this case Medicare Advantage plans, when they sign up with a Medicare Advantage plan, they're agreeing to a limited number of post-acute providers. So you don't have to give them information about those entities that don't have a contract with that particular plan. So they may limit or specify which post-hospital home health services or other services are under the plan, and those are the ones that you have to go with. And therefore, your choice list should be limited to those providers that are contracted with that patient's managed care plan, and frankly, that would apply to any managed care plan. So with a traditional Medicare patient, you know, you have a little bit more leeway in terms of choice for that patient. In a managed care contractual situation, you have less. Identify at an early stage of hospitalization those patients in need of discharge planning. So they don't say every patient should be evaluated for discharge planning, but best practice calls for that admission assessment to be completed on the day of admission whenever possible. So that's, you know, this language is kind of old, you know, when the lengths of stay were a lot longer than they are today. Provide a discharge planning evaluation for those patients identified or upon the request of the patient or representative and so forth or physician. So they're telling us we don't have to evaluate every patient, but best practice tells us that all patients should have a discharge planning evaluation. Then they say complete that evaluation on a timely basis so that you don't have unnecessary delays in discharge, and again, as I mentioned earlier, this is one of the first times they got into this. So the intent of this particular statement was to emphasize the need to complete that evaluation early in the stay, so we say day of admission is best practice. What is the likelihood that that patient is going to need post-hospital services and the availability of such services? So you must include a determination as to whether the patient will require post-hospital services, obviously what those would be. And if they're available to that patient. And this is the foundation of your initial admission assessment that you do on the day of admission. Of course, you want to put all of this in the patient's medical record, and you must discuss the results with the patient or their representative. So that's the most important part as far as I'm concerned. Putting it in the record is obvious, but discussing the plan with the patient is something you want to do early on, get them involved, get their choices, get that whole thing going. And then, of course, you have to arrange for the development and initial implementation of the discharge plan. So once you know what the plan is going to be, you have to then make those referrals, create that paperwork, and implement that plan. So that's discharge planning, that's making a plan. Let's talk about the next piece of this, transitional planning. Now I'm starting to see some folks kind of morphing the two together. But in my mind, creating a discharge plan is one piece, as I said earlier. And then transitioning the patient correctly is a second part of all of this. So it requires interdisciplinary team involvement. When you're going through this in your mind, when you're going through where you think that patient needs to go, you want to think about the least restrictive environment that can meet that patient's needs. We want to include the patient and family, and we keep saying that, but it's true. They should be educated about community resources that might be available that can help that patient maintain their maximum potential and independence. So maybe we can avoid having to place the patient somewhere if we can get some of those community resources in place and so forth, and making sure that that plan is safe. Is that going to be the right environment for that patient at this point in time? So you have to look at the patient's benefit plan and then choice. You have to put all those pieces together. So as we think about moving from the discharge to the transition, we've got some information here from the Joint Commission Transitions of Care Standards. So they said, refers to the movement of patients between healthcare practitioners, between settings, and home as their condition and care needs change. So I see the transitions piece of this as that fluid movement, actual movement of that patient. So their example, patient might receive care from primary care physician or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission, then move on to yet another care team at a skilled nursing facility. Finally, they might return home where care is received from a visiting nurse or support from family members or friends. So in those examples, there's a lot of movement of that patient from provider to provider. So it's not just setting to setting, it's also provider to provider that has to be considered during these transitions. So case management kind of becomes, in my opinion, the glue that holds all of this together. So integrated care, integrated across the continuum, really can't happen without case management. So the question becomes, do we have case managers at all of a patient's transition points? We may or may not always have that available to us. But when we do, it allows us to use case managers as the link across healthcare settings and providers, which is really optimal. So when you're considering your patient's discharge destination, you always want to think very broadly, as I've been saying, in terms of the continuum of care. So a couple of definitions here of the continuum of care. In medicine, describes the delivery of healthcare over a period of time. In patients with a disease, this covers all phases of illness from diagnosis to the end of life. And the other definition is a concept involving an integrated system of care that guides and tracks patients over time through a comprehensive array of health services spanning all levels of intensity of care. They both apply, particularly, I think, the one on the right. So this is another piece of your thought process as you are working on your discharge planning. So the continuum of care includes the services and the integration of those services. And case management is considered to be the chief integrating mechanism in medicine. Some examples of continuum of care services, you know what we're talking about here. I don't think this is an all-inclusive list. Do you? I think there's other things that could be on the list that you're probably thinking of. But I think these are some of the big-ticket items. So you want to think about the least restrictive environment, as we said, the least restrictive environment that's going to meet the needs of that patient, both socially as well as clinically. Now the American Case Management Association, ACMA, has transitions of care standards. And when I look at these, I see that morphing together of discharge planning and transitions of care. So identify patients at risk for poor transitions. Complete a comprehensive transition assessment. We talked about assessments. To me, it's a discharge planning assessment. Perform and communicate a med rec. Establish a dynamic care management plan that addresses those settings through the continuum. If we're talking about med rec, the third one there, in the hospital, that's usually done by the physicians. And communicate essential care transition information to key stakeholders. So I think they're really here talking more about discharge planning than they are transitions. But I wanted to just show you that they do have standards. So if you're a member of ACMA, you can access these. So we do have some expectations that would improve or make effective your transitions of care. You want to have a good post-acute care alignment, tracking and feedback. And we started off when the readmission reduction program started. We started meeting with our post-acute care providers, specifically talking about readmissions. But today, we have a much greater need to align with our post-acute care providers for all the reasons we've been talking about today. And remember those accountable care organizations and those, oh, I forgot, the other groups that require post-acute, of course, the continuing conversations. So we want to think about both the modality that the patient may be involved in, the payment modality. And that will involve post-acute care alignment as well. Effective and timely identification of the plan and communication, integrated electronic medical records. And again, I'm seeing that happening more and more and more between acute and post-acute. Appropriate staffing, maintain effective transition plans, appropriate roles across the continuum. Oh, my goodness, if we had case management everywhere, wouldn't that be beautiful? And ensuring transitions through leadership, mentoring, and auditing. So leaders, you have to make sure your staff are doing this stuff right. So the transitional planning process, assessment of the patient's condition, risks, and needs, assessment of the plan, implementation of the plan, evaluation, ongoing monitoring and modification of the plan, confirmation of and final prep for the patient's transition. So here we come to the transitional piece. Transition to the next level of care and follow up with the patient post-transition. One of the new terms I've been hearing more about is, you know, we've heard about food insecurity. Now we're hearing about transportation insecurity. So when you're following up with the patient who's moving to another, let's say, home, and they have issues with getting to follow-up appointments, maybe physical therapy, maybe being their primary care provider, you want to think about that too. So transition challenges, multiple providers, patients having difficulty maybe making decisions on that next level of care. The reimbursement variation, as I was just saying, any bundled payments, alternative payment models, accountable care organizations, as I was saying. And then maybe they don't have funding or a payment source for some of those next level of care needs. We need to know that as part of our process because that may change the destination. Medical delays may delay your transition. Readmitted patients, physician practice patterns, communication across the continuum has to be tight if we're not coordinating care adequately and adequate planning and goal setting with the patient. Any of this stuff that we see here. So when you're looking at some of the quality data and cost data related to your post-acute care providers, when you see facilities that have a lot of readmissions or higher cost, higher length of stay, you know, you've got to share that with your patient. That's part of the information that the patient is to be given to make an informed decision about where they want to go next. And then if they're slow to accept patients, you don't have to tolerate that. So a transition, a movement of a patient is dependent on an effective handoff. So the process is the transition. The handoff is the tool that's going to help you make a good handoff. So the Joint Commission Sentinel event alert said transfer and acceptance of patient care responsibility achieved through effective communication is the handoff. It is a real-time process of passing patient-specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient's care. So a handoff is an active process, and it requires that you do it properly. You know, it's not just that thing you do that you do in 10 seconds. It's something you really want to think about, so you're handing off that patient with the right information at the right time and so forth. And then the Agency for Healthcare Research and Policy said clinical handoffs, also known as sign-outs, shift reports, they're getting into a lot of other ways handoffs take place. Or handovers occur in many places along the healthcare value chain. It involves the transfer of professional responsibility and accountability for some or all aspects of care for a patient or groups of patients to another person or professional group on a temporary or permanent basis. I couldn't shorten that any, because I think what they're telling you here is when you pass a patient, when you hand off a patient to another provider, you're transferring your professional responsibility and accountability to that next provider, okay? So, you know, it's not something to do lightly. It's something you want to be thoughtful about. You could have verbal communication during transitions, but you should have a systemized method to make sure that the person taking care of the patient speaks to the person who will be caring, who will be caring for the patient next. I left a word out there. Electronic communication. These can both go together. You may have a checklist. So, I like a checklist that you can check off that everything was done, also called a time-out form. You know, in other words, did I do these 10 things for safe and appropriate discharge? You can also use a transitional minimum data set. I like those, too. They give you, as you fill it out, a baseline of information that you will send to the next provider so you don't forget anything, and it's consistent and done the same by everybody, which we have seen can help avoid unnecessary readmissions. So, when we talk about billions of dollars being wasted per CMS, what we're really talking about is not doing a good job in transitioning these patients, not adequately working through it as we should, and just seeing it as sort of a chore at the end of the patient's stay. You can develop your own minimum data set. I do these with my clients. Standardizing it, as we said, systematizing it and standardizing it is the way you're going to reduce errors and readmissions. So, the Joint Commission mandated standardized handoffs back in 2010, so the transition of care as well as the transfer of patient-specific information by one health practitioner to another, and your purpose in doing this, according to the Joint Commission, is to provide a patient with safe, continuous care. And they say it can only be achieved by effective communication, verbal and or written. So, what they're telling us is we better make sure we have a really good handoff process. Again, standardizing it is your best bet. And this was interesting. A typical teaching hospital may perform 4,000 handoffs every day. Imagine. Oh, my goodness. That leaves a lot of room for errors. So, ineffective handoffs can result in errors. As healthcare has evolved, become more specialized, more clinicians involved in a patient's care. I mean, think about all the specialists sometimes that get involved with one patient. Patients are likely to encounter more handoffs than in the simpler and less complex health system of a few generations ago, and that is for sure. Ineffective handoffs can contribute to gaps in patient care and failures in patient safety, including med errors, wrong site surgery, and patient deaths. So, it's seen very seriously. But they can be difficult because of all those different healthcare providers, and then including your patient and including your family. It makes it pretty dynamic, pretty complex. So, this is why, again, I keep harping on walking rounds or interdisciplinary care rounds of some sort where you can communicate on a routine basis, face-to-face, at a specified time of the day. Some nursing units may transfer or discharge 40 to 70 percent of their patients every day, and we know which units those are. And this increases the frequency of handoffs encountered daily and the number of breaches at each transition point. If you've ever studied quality in healthcare, one of the things we know is every time that patient is passed from one provider to another, that's where things fall through the cracks. If you think about a baton pass in a race, when that baton is dropped, it's likely that team is not going to win that race. And then you have your fumbled handoffs, not to use a football term, but it does apply. Ineffective handoffs can lead to patient safety problems. A study of incidents reported by surgeons found communication breakdowns were a contributing factor in 43 percent of incidents. Two-thirds of these communication issues were related to handoff issues. The use of sign-out sheets for communication between physicians is a common practice, yet one study found errors in 67 percent of the sheets. I think I have absolutely observed that. I have seen a lot of physician-to-physician breakdowns. Sometimes your doctors who come in in the morning have, like, no idea what happened overnight with the patients they're picking up. Really scary. Really, that's a fumbled handoff. Errors would include missing allergy and weight information, incorrect medication information. I'm sure more than that. Another study focused on near misses and adverse events involving novice nurses. The nurses identified handoffs as a concern, particularly related to incomplete or missing information. So nurses get their handoff when they come on duty. Case managers, you should get your handoffs between each other, whether it's the RN case manager or the social work case manager. You should make sure you've got a tight handoff process, even in writing. And what happens over the weekend for you guys when the staffing goes way down? How do you know from Friday to Saturday what has to be followed up on? Well, you need a handoff sheet to do that, too. And then this notion of chasing after team members, right? I mean, come on. We have such complicated healthcare systems. If you have to find the doctor all day long, if you have to find the physical therapist, this is why having some kind of organized meeting, walking or otherwise, every morning reduces the need to chase after team members. So when I hear folks say, oh, we don't have time for rounds, rounds reduces the need for some of these other things that are big time wasters, really, and irritating. Because if I know I have to come to rounds at 9.30 in the morning, I'm going to come prepared to discuss all the different things that are to be discussed. And then instead I get tapped all day long for information, interrupting my workflow, and I may not be prepared to answer a specific question. So really important to have some kind of interdisciplinary rounding or meeting process. So implementation expectations for effective handoffs include three things, interactive communication, allowing for the opportunity for questioning between the giver and receiver. So if it's just paper handoffs, it's one modality, but verbal communication, again, among team members is considered to be more effective. You should have the most up-to-date information, and that should include the patient's care, treatment and services, their condition, and any other recent or anticipated changes. And then a process for verification of the received information. It could be repeat back or read back as appropriate. Now you're probably thinking, oh, my goodness, there's so much. But if you want to ensure a better outcome for your patient and you want to decrease your readmission rate, you've got to do this stuff. Understand the influences on your transition for that particular patient. Is the patient the issue, is the family or the caregiver the issue? Follow your case management processes. And post-acute care processes should also be considered as well as the physicians themselves. Understand which patients are part of those alternative payment models that I couldn't think of before, and how to collaborate with those case managers. So there should hopefully be a case manager in an accountable care organization or a patient-centered medical home or maybe in a bundle payment. I'm not sure about that one necessarily, but most of these others do have case managers on the flip side there that you should be communicating with. And then again, those staffing challenges that I just mentioned should be considered at all times. So for our transitions, we have input, throughput, and output. So where the patient came from is going to impact on your discharge plan and the destination that you select with your physician and your patients and families. And patients enter in different ways. They might transfer in. They may be waiting for an admission in the ED or a scheduled or planned admission. They may be coming from a physician office, from procedure, outpatient procedure, from ambulatory surgery, or an outpatient clinic. They may be coming from a long-term care setting, like an LTCH or a nursing home or a SNF. They may be coming from acute rehab. You need to know as part of your assessment where they came from, because that's, again, going to inform you as you move toward the final patient destination. And then, of course, we have throughput, intra-hospital transfers. How well do we as case managers communicate when the patient moves to these different levels of care, from the ED to a med-surg unit or to telemetry or intermediate care or back or to critical care or back to a PACU or a holding area? Maybe they're, you know, going to be discharged. We see these holding areas next to emergency departments where patients are sometimes observation, sometimes not. I've seen so many variations on the scene with these holding areas. I can't give you one explanation of what they are. And then output. Where is your patient going? Are they transferring to another acute care hospital for a higher level of care, for a lower level of care? You would only transfer a patient to another acute care hospital to a lower level of care if they had come to you first for that higher level of care, and now you're returning them. And a lot of times, those facilities don't want to take the patients back. So you want to make sure you've got a document, a return document that's signed by both organizations, reverse NICU transfers and psych or discharge to next level of care facilities, LTACs, rehabs, SNFs, and nursing homes or discharge to next level of care as home with home care or DME or discharge home without any services or just primary care. They should all really have primary care. So you want to think about that output as we've talked about. So I mentioned the influences on your transition related to patient and family, getting them to agree to a plan. The word discharge maybe is scary to them. Perhaps, you know, they're thinking, oh, my God, you know, that's it for me. So sometimes not using the word discharge can be helpful. Maybe use the word transition. Timeliness in making decisions, particularly maybe picking a nursing home, things like that, you know, can sometimes be slower. Decision-making, particularly around end-of-life issues, can be hard and slow too. Oh, and the good old family dynamics. I've done a couple of studies looking at why some long-stay patients stayed longer than expected. And sometimes number one on the list was family. Other than patients who are acute and appropriately in the hospital, the next biggest category was family dynamics. And that can affect the agreement with the plan and the timeliness in making those decisions on the top there. And geography, you know, where is that patient going to go? When you think about appropriately doing transitions, you really do want to think about the patient and family. So I wanted to spend a couple of minutes talking about how that all makes sense coming together. So transitions for patients and families can be upsetting and disruptive. They can be confusing. The patient may be going to a setting where there will be new providers, new rules and regulations, new financial requirements, new care plans. So, you know, this is, for some patients who maybe have never been to that level of care before, can be very overwhelming and daunting. A nurse advocate came out with this. Family caregivers are the unsung heroes of the healthcare system. Studies show that about 44 million Americans provide 37 billion hours of unpaid inpatient care with unpaid informal care each year for adult family members and friends with chronic illnesses or conditions that prevent them from handling daily activities such as bathing, managing medications, or preparing meals on their behalf. So, yeah, you know, you can have an informal caregiver, and by that we mean somebody who's not being paid. So family caregivers are typically not reimbursed for the care that they're providing. So they may be taking care of ill or frail family members or even friends or neighbors. They can be the family caregiver in any setting, home, hospital, rehab, anywhere. How do you know if they are a caregiver? So I just gave you these four points. They take care of someone who has a chronic illness or disease and or they manage medications or talk to doctors and nurses on someone's behalf and or they help bathe or dress someone who is frail or disabled and or they take care of household chores, meals, or bills for someone who cannot do these things alone. So if you go over to your neighbor's house and you help them fill out their checks for their bills for the month or you go food shopping for them, you're a family caregiver. You're doing it as a kind neighbor, but you're providing a service to that patient, and by providing that service, maybe you'll help keep that patient in their home for a longer period of time. And this is why family caregivers and healthcare professionals have to work together, particularly during these times of care transition or change in care setting. These are really the most important points at which we want to make sure we're pulling them into the discussion and having really good communication with them. And to do that, we want to see them as part of the healthcare team. What do they need? They need a basic understanding of how things are expected to work in the new setting that the patient is going to. A chance to ask questions, and when they're ready to ask those questions. If you have any guides or materials, written information you can give them, that helps them. And acknowledge their role as a family caregiver. You know, pull them in. By pulling them in, hopefully they'll see themselves as a family caregiver. And when they are the family caregiver, they can act on their rights and authority to get information about the family member's condition, the right to be involved in decision-making about care, and the right to be an essential partner on the healthcare team and be educated in how to provide care. And to me, number three there is the key for our discharge planning discussion today, because having a family caregiver as part of the team is going to inform your discharge destination selection, whether or not that patient will be able to manage in the community or in their home, I should say. And then physician practice patterns. Yes, those can influence your patient's transfer or transition. Planning. Are they planning? Are they thinking ahead? Are they working directly with you on that plan? Their own perception of the word discharge. Their critical thinking skills. You may have to talk to them about options for that patient that they may or may not be thinking about. They may not have a financial incentive to transition that patient timely. And I hate to have to say that, but the truth of the matter is medical physicians from the community are paid each time they visit the patient at the bedside. Now, today we have so many more hospitalist programs, and so I think that particular incentive has diminished because of that, but it's still there. And surgeons, you know, they get paid once for that surgery, so they're usually more on top of the discharge planning stuff. The reticence, perhaps, of a physician to have that conversation with the family about end-of-life issues can slow things down. Waiting for a lot of consultants. And you always want to ask yourself, if there's a delay in discharge because of a consultant, can that patient see that person after discharge? I had a case in one of my hospitals where the patient wasn't even an inpatient. They were an observation patient, and they were holding the patient, waiting for a speech evaluation. Well, that clearly could have been done, you know, in the physician's office, not hold that patient in observation for two days. As I said, hospitalists' impact. Hospitalists, hopefully, are having a very positive effect. The whole point with hospitalists was to align them with the hospital. They're getting paid by the hospital. They should have the same goals, right? So the hospitalist impact, hopefully in a positive way. And then, again, those relationships that we've been talking about with your post-acute providers. And then other regulatory and payer issues that may impact on your transition. When the payer is giving you a limited choice for the next level of care. How long it takes to get that approval. If you have on-site reviewers, you know, don't like those, but I still see them some places. Contractual agreements with that payer that you may or may not know about. The type of reimbursement the patient has. If the patient was going to pay and that goes bad, they're not going to pay. Maybe for home care, for example. And contractual limitations after discharge such as that. And then all the regulatory stuff, the Balanced Budget Act of 1999, the right to choose among Medicare providers. The important message, which would include the Medicare Discharge Notification Appeal that we talked about last week. Or we didn't. Maybe I didn't. I don't remember. One- and two-day stays. Those short stays for observation where you have to give the moon. And then the three-day stay rule. All this stuff, you know, all these regulatory things that you're like, why do we have to think about these? Well, because they do impact on your work on a daily basis. And then hospital issues. You can think about some of this as avoidable delays, but delays in service, hospital-acquired conditions, safety events, poor communication, I would say, among team members. If you have good communication, that should help. Incomplete documentation. So the documentation in the medical record doesn't really tell the story. Collaboration delays and or omissions that happen because you don't have walking rounds or huddles or interdisciplinary care conferences or team conferences. I mean, walking rounds are considered best practice, but if you're not ready to do that, have some kind of team meeting where you can go over these issues. Ineffective hospitalist services. Some hospitalist services can be the best thing since sliced bread, and sometimes they can also be a barrier. So, I mean, if any of you struggle with that, that's really unfortunate because they should really align with case management. Or if you have an ineffective physician advisor. And then stuff related to case management. Our own processes, our own delays may be due to staffing. Relationships between the case managers and the social workers. The skill sets of the case managers and the social workers. Critical thinking skills, sense of urgency. Your own case management intelligence. You know, it takes at least a year to become a really good case manager. This is not an out-of-the-gate, imperfect kind of a thing. It takes a good year. The skill sets and workload, those become interrelated as well. You can be a really great case manager, but if you have too many patients, you are not going to do as good a job. It's just logical. We're going to talk more about that in our fifth module in a couple of weeks. The role of your manager or director. Are they outcomes-focused? Are they data-driven? Are they influenced by data? Do they change processes based on audits of records and continuously educate the staff? And then again, that lack of integration across the continuum. If case management isn't reaching across the aisle, then again, it's going to reduce the effectiveness of your acute-post-acute relationships. So if you have case management at all patient touchpoints, as I said before, that is a great thing. So you do want to have a case manager for those admitted patients and or transfer patients. You have to have ED case management. You must have a perioperative case manager if you're in a hospital that does a large volume of surgeries. Inpatient case managers, obviously. And then those community case managers. I've done it. I can tell you it's great. If you have a patient-centered medical home, you can follow those high-risk patients there or in a clinic. Also, subacute home care and long-term care have some elements of case management, too, once they went to the prospective payment systems that they have, as we talked about in Module 1. The other position that you may want to consider is a transitions case manager. This is a specific case management role where this case manager follows high-risk patients while they're in the hospital and during the first 30 days after discharge to the community. So high risk. High risk for readmission. High risk for poor outcomes. You know, they have to do an assessment. They are following the patients telephonically. So this is a telephone relationship. It's up to 30 days, or sometimes it's extended, to make sure these patients don't wind up back in the hospital. If there is a community case manager available to the transitions case manager, they should be interfacing with them or any case manager in any of the locations across the continuum. So what are those high-risk criteria that they might be looking for while the patient's in the hospital? As I said, frequent readmissions, maybe looking for specific diagnoses that you know are more risky for your patient population, particularly chronic conditions that are maybe not so well managed by that patient, or patients with frequent admissions and sometimes inappropriate admissions. So there's avoidable readmissions. There's also avoidable admissions. Level of care issues. You want to use the next level of care appropriately, and that means the whole team has to think about that. And you want to think about the nursing home's use of SNF days, those that don't accept patients on the weekends, home health delays and seeing the patient. You want to work with a home health agency that's going to see the patient the next day after discharge. You don't want to work with a DME company that is delayed all the time in delivering equipment or services to the patient. Now, I remember back in the day when we had particular nursing homes, specifically nursing homes that would just take everybody. And so without a lot of thought, most patients were just, you know, sent there. We can't do that anymore. We have to look at those post-acute care providers that are not... Well, what we have to do, excuse me, is look at the post-acute care provider in terms of their quality rating, in terms of their use of resources, and provide that to the patient, all complete information. They should prove their worth to receive referrals from us. Those that are two stars, God help us, one star, these are not facilities we want to use, and we want to have that conversation with the patient when we talk to them. You know, if they start not getting referrals because of quality of care issues, maybe they'll improve. We should expect high-quality care and outcomes, also for our own hospital-owned acute care provider and post-acute provider. And as we've talked about a couple of times, we want to make sure we know what other networks those patients might be in. Having effective post-acute care transitions, we've seen decreases ED utilization, so if you're really on top of that patient, you know, particularly our transitions case manager, we can reduce the number of times maybe that patient comes back to the ED, gets readmitted. That decreases costs and improves quality and patient satisfaction. So it all kind of plays off itself. So let's talk about these. Let's see. We have several slides here about interventions that you can use to improve your transitions. And these are all tried and true, okay? So post-discharge follow-up phone calls, you only need really to call patients who are going home, going home with or without services. The ones going home without services you want to call too because, you know, it may turn out they need something. You want to connect the patient to a primary care provider if they don't already have one. So that should be part of your process. Ensure that essential discharge information is transmitted. So as we talked about, that handle of communication should be standardized so that everybody is sending complete and accurate information to the next care provider or caregiver, for that matter. Standardize your discharge process, including your off hours and weekends leaders. Actively engage the patients and families to realistically assess their potential, to have them participate in discharge planning that achieves successful care continuity when the patient returns home. And we know getting that patient to a realistic family, I should say, to a realistic plan sometimes is tough. Oh, yeah, I can manage that. I remember my worst-case scenario was a patient who was going home, you know, with tube feedings and had a drain, and the family's like, oh, yeah, we can manage that because it looks easy when the patient's in the hospital. They get home, and within a day, that patient's back in the ED. So sometimes it's, you know, it's difficult communication that you have to have with them and explain to them that this is probably not realistic. They may or may not go along with you, but you should absolutely try. End-of-life issues identified earlier during that inpatient admission and talking about them before discharge is also an important piece of this. Connecting patients who require complex care. Get them into a medical home or some other outpatient program where they can access support seven days a week, 24 hours a day, and there are such programs. Implement ED case management. You cannot have a contemporary case management department anymore unless you've got RN case managers and social workers in the ED because from the ED, maybe a patient can return to a nursing home or some other post-acute service, or maybe they need to be admitted. And what level of care? Maybe they only need observation. Work with your local primary care providers, your nursing homes, or other providers to develop strategies to prevent avoidable readmissions. One of my big success stories was working with our most utilized and owned, I would add, nursing home because they kept sending patients back to the ED for minor things that really could have been taken care of in the nursing home, and it required nursing education in the nursing home. And we did that on a number of different things and reduced the number of times those patients were sent back to the ED. On your readmitted patients, are they seeing a primary care provider? Are they seeing them routinely? Make sure your discharge summary gets to the referring physician. And that's usually done electronically these days. But particularly important if the patient had a diagnostic test or a laboratory test and the results were not back before the patient left the hospital. Some of those laboratory tests can include critical values, meaning they need to be acted on by the physician. So make sure the physician knows this patient had this test or this laboratory work done before they left the hospital. Again, standardized processes, including to your MD offices. Improving the standardization of the discharge process, as we discussed earlier. Improving delivery of discharge instructions, especially those who don't speak English or have low literacy rates. So how do we communicate with folks in a manner that they're going to understand and be able to work with us on? And improving the med rec process, but not just in the hospital, also at home. So this whole transitions of care continuum, it's pretty complicated. And so I wanted to just hit on a bunch of the different locations where our patients do go, because sometimes, you know, you have to think through what the requirements are, what the clinical requirements are beyond just the patient's financial coverage for some of this stuff. So I'm not going to have enough time to read through all these, but I would keep these, you know, maybe little pocket cards for yourself. Will they, you know, for an inpatient rehab facility, they have to tolerate three hours of therapy per day, up to six days a week. They are seen by physiatrists at least three days a week. They have to benefit from therapy. They have to make practical improvements or adapt to impairments in the prescribed period. So they don't need to achieve complete independence or return to a prior level of function. That is not a requirement of acute rehab, and you will hear that sometimes from insurance companies. So you want your physical therapist to say, this patient requires three hours of therapy a day, not say transfer this patient to inpatient rehab, because they may not have coverage for inpatient rehab. Subacute, what I call subacute short-term rehab, I've heard it called that. So this is after the patient's met their acute outcomes and they can continue to be managed in a less intensive setting. So in this case, it's 1 to 1.5 hours of therapy a day. They can also get short-term complex medical or restorative care. It's not just rehab. Ventilator weaning, we've done a lot of that in the subacute setting. Or even patients with long-term chronic or preventative maintenance needs may qualify for subacute, where the average length of stay is 7 to 30 days. Now, this is important, and I want to really emphasize this, because when we do discharge planning, we don't always think about things other than rehab when we think about subacute. Look at all the complex medical stuff that would qualify. Post-surgical recovery, respiratory, pulmonary management, oncology, AIDS, wound care, trachs and suctioning, parenteral nutrition, IV therapies, terminal care, dialysis, lots of stuff. In the rehab section in the middle, we're familiar with all of that kind of stuff that would be subacute. Some, of course, might be acute rehab. And then even long-term chronic. Some of this can be in subacute. Comas, where the patient probably isn't going to recover. Multiple trauma, ventilator dependency, and head injuries. And then skilled nursing facilities, of course. Daily is 7 days a week of skilled nursing and or therapy or 5 days a week of therapy. So that's the basic requirement for a SNF. Skilled, by their definition, is a task that can be safely and effectively performed only by a professional or technical personnel. So they have to have a skilled need, obviously. Generally, they're admitted to a SNF within 30 days of a 3-day inpatient hospital stay. And again, most of your Medicare Advantage plans waive that. So bridging your interventions for SNF readmissions. So you want to work on teams. This is an example I gave a little bit ago. If you have an acute post-acute team, you can look at root causes of readmissions for that facility or home care agency. Look at the data. Coordinate quality improvement efforts. This is exactly what we did. So it's not really an exercise in futility. A lot of good stuff can come out of this. ED engagement or protocols regarding the return of a patient. Back to the SNF. So even if the patient has to go to the ED, everybody knows the protocol for when that patient should be returned to the skilled nursing facility. Medication reconciliation is there at the SNF. Goals of care that are given to the patient and physician warm handoffs, bidirectional. So the physician should be involved as well. So you may remember I gave you this example. In October of 2021, otherwise healthy Mr. C, age 80, was hospitalized due to cardiac concerns and renal failure. Knowing his recovery would be lengthy, he asked for but didn't get a case coordinator from the managed care plan. After six weeks it was time to leave the hospital, but he was deconditioned, so his doctors wrote orders for Mr. C to be transferred to an inpatient rehab facility for intense multidisciplinary therapy to regain his strength. But Mr. C's Medicare Advantage plan denied acute rehab prior to authorization stating, quote, your doctor must expect you to improve a lot in a reasonable amount of time. Okay. Now is what do we do with that? When in doubt, go to the benefit manual. It's there, and it's really easy to navigate. So I pulled this out of their Chapter 1, Section 110.2. The patient can only be expected to benefit significantly from the intensive rehab therapy program if the patient's condition and functional status are such that the patient can reasonably be expected to make measurable improvement that will be of practical value to improve the patient's functional capacity or adaptation to impairments, and that clearly applied to Mr. C. As a result of the rehab treatment as defined in Section 110.3 and if such improvement can be expected to be made within a prescribed period of time. CMS notes that an IRF claim could never be denied. It could never be denied, one, because the patient could not be expected to achieve complete independence in self-care, or two, because the patient could not be expected to return to his or her prior level of function. So those are not reasons to not approve an acute rehab. So coverage of nursing and or therapy to perform a maintenance program does not turn on the presence or absence of an individual's potential for improvement from the nursing and or therapy, but rather on the beneficiary's need for skilled care. And skilled services are defined. Skilled care may be necessary to improve a patient's condition or to prevent a slow, further deterioration of the patient's condition. So hold on to all of these policy manual defenses as you come upon these different issues because you'll keep looking. Go and look them up because when you know in your heart and your gut that this denial is wrong, then, you know, go to the Medicare benefit manual and pull up your evidence and use it on behalf of your patient and hold on to the ones you've already looked up so you don't have to look them up again because you know the issue will happen again. And we have LTACs versus SNFs, distinct care settings. So I've had questions sometimes about the differences or similarities between skilled nursing facilities and SNFs. So long-term acute care hospitals have very specific admission criteria, and I'm going to show you that on the next slide. On-site physician visits at least once a day. Subacute specialists are on location, whereas in a skilled nursing facility, on-site physician visits at least once every 30 days and only for the first 90 days. You have to go off-site to see a specialist. Staffing for LTACs is one to six. Nursing home is 10 to 40. Limited respiratory therapy in select locations, whereas 24-7 respiratory therapy in-house in LTACs. On-site services such as tele, radiology, pharmacy, lab, and dialysis. You have access to all of those, but off-site with a skilled nursing facility. And then air quality ventilation systems are hospital-level at the LTAC and residential-level at the SNF. So here's your criteria for LTACs. Now, I can tell you that sometimes they have their own more rigid criteria and will deny a patient that does qualify based on the Medicare guidelines. So they have to have complex medical conditions. They typically have complex and multiple illnesses, or they may have chest tubes, multiple organ failure, vent needs, or wounds. The average stay is 25 days or more. There are clinical guidelines for LTACs. These guidelines may include criteria from sources like Interqual or Millman. So, you know, again, use these if you need to. Mechanical ventilation. The patient must meet specific criteria related to mechanical ventilation. For instance, they may need more than 96 hours of mechanical ventilation. So their admission process follows this course. You must meet your clinical guidelines for admission, whichever ones you're using. A three-night stay in typically a critical care unit must precede the LTAC or will have greater than 96 hours of mechanical ventilation need at the LTAC. Referrals can be made by anybody. A clinical liaison would come and assess the patient to see if they qualify. And again, that patient must come directly from an ICU. They will need daily assessments and interventions due to the potential for rapid and unexpected deterioration, and they may continue drips, IV meds, and most tubes. So this is a follow-up to your critical care unit where the patient continues to need this higher level of care. Swing bed criteria. We are so short on time, but I do get asked this question quite a bit about swing bed admission criteria. So please use this also as a reference for yourself. The patient must have a three-day qualifying inpatient hospital stay or critical access hospital stay. So that's the first criteria to swing to a SNF level of care. Medicare will cover up to 20 days in full and up to 80 days with a copayment. Stability and skilled care. The patient has to be stable and require daily skilled care or rehab five days a week. You need a physician's authorization for a swing bed admission. The patient has to have Medicare Part A or another insurance plan that covers the cost of swing bed care. So you have to figure that one out. For you rural hospitals, hospitals must be in a rural area. They should have less than 100 beds, a Medicare hospital provider agreement, and swing bed approval should not have been terminated within two years. So swing beds are found in rural areas. They're found in critical access hospitals. And make sure you document everything in your medical record. And home care. We don't want to give short shrift to home care because it's probably or should be the greatest used, if that sounds right, level of care after discharge. Medicare patients should have at least one home care visit, and I get crazy when the home care agencies don't want to take a patient because they're anticipating it's going to be one visit. You have to push that point, too. In the home, med rec can be repeated. Really important when that patient has bags of meds, different doses of the same medication, they just got something new and they haven't even taken it yet, things like that. And you can have your home care nurse reinforce medication in the home as well. So what are the referral criteria for home care? Well, here they are. Not my criteria, but Medicare's criteria. Now, if you look at the very top one, patients requiring assessments or education relating to a new diagnosis, new medication, or change in medication, that's three-quarters of the discharges. New assistive device. Maybe they're going home with a walker for the first time. And you can go on, you have a wound vac, a pressure ulcer, ostomies, trachs, of course, any of that kind of stuff. IV injectables, obviously. Pain control management, and so on and so forth. So references, too. When you get a pushback from your home care agency, use this. My patient has a new diagnosis. My patient has new medications. My patient has had change in medication. Or they have a new assistive device. Use that to your advantage when there's a problem. Even patients re-hospitalized within 60 days or known history of repeated hospital readmissions. They like that. So use your guidelines. Refer to your guidelines on admission, on rounds, case conferences, inquiries, or when you review your medical record. Because what may not seem appropriate for home care at one point in time may become appropriate. And then the definition of homebound status, also often misinterpreted and worth a quick review. Somebody can be homebound because it takes a considerable and taxing effort for them to leave home. They need help of another person to leave home. They need an assistive device to leave home. They need special transport. Or when they leave home, their symptoms are exacerbated. Okay? They can leave home, but it takes a considerable and taxing effort. Patients who leave home infrequently for short durations or for health care may still be considered homebound. So you can go to an adult day program, an outpatient medical care, a religious service dialysis or the hairdresser and still be considered homebound. So don't let people throw that one at you either. And then those post-discharge follow-up calls, which can be extremely effective for patients going home with or without home care. You can have a standardized list of questions. You can have a clerical person ask these questions, and if you get the wrong answer, be it a yes or a no, then it's ratcheted over to the nurse or social worker. But you can catch a lot of stuff with these post-discharge phone calls. Let's not forget palliative care. It's just simply not used as much as it could be. This provides patients, and it doesn't have to be end-of-life. It could be patients who need relief from their symptoms of pain or physical or mental stress related to a serious illness. So it's not dependent on the diagnosis, but on these other symptoms that they may have. It can be at any age, at any stage in a serious illness. And when you have an interdisciplinary palliative care team, they're looking at physical, spiritual, and social concerns that may arise for that patient who has an advanced illness. And lastly, of course, hospice care, end-of-life care. It could provide palliation without a curative intent. They provide medical, psychological, and spiritual services. They want to also manage pain. So this is the little bit differences. This is for end-of-life patients expected to live six months or less. And patients can go on and off hospice, too. So sometimes to soften it a little bit, you can say to the patient, it might be a good idea to go on hospice right now, but you can always change your mind and go off hospice. Otherwise, it sounds very, you know, finite to them. Hospice, as you know, can be at home hospice, a hospice center, or even in a hospital that has qualified some of their beds as hospice beds. I'm losing my voice. All right, we've got quite a few references today because this is a lot of information, and it does go on and on and on. All right, well, with just a few minutes left, Lindsay, I'm going to... I'm sorry, I knew I had a lot of stuff again today. I can't help it. No, that's great. I don't want to leave anything out, you know? No, no. Here we are. I'm thankful that you went thoroughly into all this information. I know all of our attendees do as well. There are just a couple of questions, so before I give some closing comments, I'm just going to go over these questions, and if you have a question for Dr. Sesta, go ahead and be tapping that into the Q&A option found there at the bottom of your Zoom window, or if you don't see that, you can type it into the chat, of course. This first question asks, is an IMM required if a patient is choosing to discharge on hospice? I had heard that a hospice discharge was exempt. That is correct. Okay. You do not have to give an IMM to a hospice patient. That's correct. Okay, and this last question I see asks, if a patient is going to be less than 30 days, do we still need to do a PASSAR? If they're going to be less than 30 days somewhere in the hospital, and you're talking about a PASSAR, yeah, I think you have to do a PASSAR regardless of that. Yeah, pretty sure. Melissa, I see that question came from you, so if you have any additional questions, you can type that in, and we'll be happy to help. And I'm just posting some information there for you all in the chat. Just as a reminder, if you have not joined us for the first two sessions, then just expect to receive an email in the morning. It will come from educationnoreplyatzoom.us, but because it comes from that Zoom email account, it may very well get caught up in your spam, quarantine, junk folders. So if you don't see that in your inbox in the morning, I would encourage you just to go to check those additional folders first. And if it's still not there, but you'd like to just access the recording of today's session, we do record these sessions as on-demand, meaning that you can use that same Zoom link that you used to join the live presentation to also access the recording. And the recording is available for 60 days from today's date. Now, we do have an additional security measure in place that we're protecting Dr. Sesta's intellectual property here. So when you click on that Zoom link, it will ask you to enter your information, and that will prompt an email to come to us for approval. We approve those requests very quickly, typically within just a few moments of receiving them, but we ask that you give us one business day to grant those recording access requests. And then again, you will have full access to the recording for 60 days from today's date. Also included in that email tomorrow will be a link to the slides that Dr. Sesta provided for us today, but I did go ahead and provide that link there for you in the chat to have as a resource now as well. And then if you are joining us as a member of the Georgia Hospital Association, if you have any questions about continuing education credits, just remember that we will make sure that you all receive a link to a survey after the final session in the series. And if you're joining us as a member of a partner state hospital association, please reach out to your contact at your association with any questions regarding CEs for this series as well. You do see Dr. Sesta's contact information here on the screen. I know she's wonderful about being very timely and thorough in her responses to any follow-up questions that you have, and we're so thankful for her doing that. So you can reach out to her directly, of course, but you can always reach us at education at gha.org, and we're happy to help answer any questions or pass along questions to Dr. Sesta as well. Okay, Dr. Sesta, we are right at noon Eastern time, and I don't see any other pending questions. Thank you so much for joining us today for all the time and information that you shared with us, and thank you to all of our attendees. We look forward to having you back with us next week for part four. I hope you have a wonderful afternoon. Thank you so much, Dr. Sesta. Thank you. Thank you. Bye, everybody. Bye-bye. Thank you.

discharge planning

transitional planning

healthcare

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social drivers of health

patient transitions

length of stay

healthcare costs

holistic approach

regulatory framework

IMPACT Act

interdisciplinary approach

patient safety

communication

post-discharge