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Insiders: Hospital discharge planning is still a mess

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Patient advocates say hospitals should do a better job of helping patients pick the most appropriate post-hospital care options, not just steer the patients to sister facilities that need the business.

The patient advocates were commenting on a batch of proposed regulations developed by the Centers for Medicare & Medicaid Services (CMS). The draft regulations would affect how hospitals that receive Medicare or Medicaid handle outgoing patients.

CMS officials hope to improve the quality of post-hospitalization care and cut the cost by promoting access to good follow-up care and reducing the chances that patients will return to the hospital soon after they leave it.

One provision, for example, would require hospitals to conduct discharge evaluations for every patient, as well as creating the discharge plans already required. Another provision would require hospitals to help patients get access to quality rating information and state inspection reports for the post-hospital-care facilities offered. Hospitals would also have to keep track of what happens to the discharged patients.

Because Medicare and Medicaid are so big, any rules they adopt could affect hospital discharge planning for patients with individual major medical coverage or employer-sponsored group health coverage as well as for patients with Medicare or Medicaid coverage. Discharge planning rules could also affect the likelihood that holders of products such as short-term care insurance (STCI) or long-term care insurance (LTCI) will end up filing claims, or using up their benefits.

Comments on the draft regulations, which appeared in the Federal Register earlier this month, are due Jan. 4.

Denise Pott, a medical social worker who has already filed a comment, says she fears CMS could make matters worse by encouraging hospitals to tell patients about even fewer post-hospitalization options.

“First, there’s the profit motive,” Pott writes. “Health systems want patients to continue in their system to boost profits.”

By requiring affected hospitals to do more to follow up on patients, the proposed CMS regulations could give a hospital even more of an incentive to refer patients to a facility with the same owner, because Health Insurance Portability and Accountability Act (HIPAA) health privacy rules make tracking patients who leave a health care system difficult, Pott writes.

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Pott says she has heard of one health system in her area that “blamed social workers for not channeling all patients to their own rehab facility.” The health system gave responsibility for discharge planning to nurse case managers, who were more willing to send the patients to the system’s rehab facility, she says.

Requiring hospitals and post-hospital-care facilities to use compatible record systems could help a hospital discharge a patient to providers outside of its system more easily, Pott says.

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A patient advocate with developmental disabilities also talks about electronic health record (EHR) compatibility.

“One problem I am having with the electronic record is that every health care system has a different software program, so my doctor only gets the information from the health care plan he is part of,” the patient says. “Also, I now have at least three different health care records that require different password requirements.”

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Other commenters say CMS has to find some way to make sure patients and families really do get the required post-hospital-care facility quality information. 

CMS should require insurers to get the quality information from the facilities, so hospitals can refer patients who want the quality information to their insurance companies, according to an anonymous hospital case manager.

An anonymous home care manager says the heart of improving discharge planning will be persuading hospitals to share information with all of a patient’s post-hospital care providers, making sure all providers take responsibility for implementing the discharge plan, and explaining the discharge plan to the patient. ”Discharge instructions should not look foreign to a patient/caregiver at time of discharge,” the commenter says.

An anonymous hospital social worker says CMS has underestimated the cost of conducting so many discharge evaluations.

Conducting a good discharge evaluation takes a social worker an average of at least half an hour each, and “some critical access hospitals do not have social workers to begin with,” the social worker says.

“Even if hospitals can afford to hire additional social worker staff to comply with these provisions, it’s often difficult to find social workers in rural areas willing [and] able to take what would likely be part-time positions to augment the current social work … staff,” the social worker says.

CMS has suggested that nurses could help with discharge planning, but many hospitals face a nursing shortage, the hospital social worker says.

If CMS really wants to avoid preventable readmissions in rural areas, it should do more to improve patient support services, such as transportation services, at their location; it should do more to make sure patients can pay for the recommended follow-up services; and it should get insurers to agree to pay for patients to stay in the hospital for an adequate length of stay, the social worker says.


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