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  • CMS Hospital Discharge Rule Puts the Focus on Patient Choice, Goals in Postacute Care

    In this review: Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies, and Hospital and Critical Access Hospital Changes to Promote Innovation, Flexibility, and Improvement in Patient Care (final rule)
    Effective date: November 30, 2019
    CMS Press Release

    The big picture: A better patient discharge process that falls short in some areas
    The US Centers for Medicare and Medicaid Services (CMS) has released a final rule intended to support patient preferences around discharge planning for a move from a hospital or critical-access hospital (CAH) to a home health agency (HHA), skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), or long-term care hospital (LTCH).

    While the new requirements include APTA-supported changes that help put patients at the center of discharge to postacute care (PAC) providers, the rule lacks provisions that would strengthen patient choice by including physical therapists (PTs) on the discharge planning team.

    The rule goes into effect on November 30, 2019.

    Notable in the final rule

    • Patients will receive a list of potential PAC facilities for discharge. Under the new rule, the hospital's discharge plan must include a list of the HHAs, SNFs, IRFs, or LTCHs that participate in Medicare and that serve a particular geographic area—in the case of HHAs, that would be the area as defined by the HHA; in the case of SNFs, IRFs, and LTCHs, it would be the geographic areas requested by the patient. The discharge planning team would also share key performance data related to the PAC providers under consideration.
    • The process for providing the PAC provider list is designed to keep the playing field level. In response to commenters who asked how hospitals and ACHs can avoid steering patients toward 1 PAC provider over another, CMS states that facilities are required to present objective data on quality and resource use measures specifically applicable to the patient’s goals of care and treatment preferences for all available PAC providers. Providers will also have to document all interactions around PAC care in the patient's medical record.
    • Patient goals must be the focus of the discharge plan. In an effort to create a more patient-centered process for discharge, CMS makes it clear that the plan must focus on the patient's goals and treatment preferences, and must include that patient and/or her or his active partners in the planning process.
    • Patients will be entitled to access their medical records. The final rule establishes that patients have the right to access their medical records in whatever format they prefer, providing that format is able to be produced.
    • HHA discharge planning time estimates will get an additional 5 minutes. CMS upped its estimates for the time it should take HHA PTs or nurses to complete information for discharge from the HHA from 5 minutes to 10 minutes. Some commenters advocated for as much as a 15-minute estimate, but CMS believes that most discharges will be uncomplicated and that the 10-minute estimate will be closer to an overall average.
    • The HHA discharge process will supply more information to patients. HHAs will be required to provide more information to patients who are discharged or transferred to another postacute care provider to help them select a provider that meets the patient’s needs and goals.

    What the rule doesn't do

    • PTs (and other relevant providers) aren't part of the discharge team requirements. Despite APTA and other commenters advocating that providers such as PTs, nutritionists, mental health professionals, and others be required to be included in the discharge team, CMS didn't make any changes, citing potential increases to the cost and complexity of the discharge process
    • Rehab nurses and respiratory therapists won't be required, either. CMS refused to follow the recommendations of some commenters that rehabilitation nurses and respiratory therapists be involved in the discharge needs evaluation and creation of the final plan.
    • Discharge instruction requirements aren't as detailed as in the proposed rule. Commenters expressed concerns with the proposed rules’ overly prescriptive discharge instructions for hospitals. CMS acknowledged these concerns and didn't finalize the requirements; however, under the new rule, hospitals can develop discharge instructions or share discharge information in accordance with applicable law earlier than the time of discharge.

    APTA will provide information on how to comply with the new requirements as it becomes available.

    Comments

    • I would like to know how other hospitals are going to be meeting these requirements. Please provide info on how to comply w these req.

      Posted by amanda taylor on 10/3/2019 1:58 PM

    • I am wondering how this new rule affects the provisions of the BCPI CMMI for major joint replacement or hip fractures? It seems that this rule overrides the focus of discharging patients home instead of other post acute care providers.

      Posted by Lisa Harrison -> ?OT_< on 10/4/2019 10:26 AM

    • We are an rural acute care hospital that has a 10 bed Geriatric Psych unit. Is this considered an Inpatient Psych Hospital. We just have a 10bed unit in our acute care hospital. Thank you.

      Posted by amanda taylor on 12/3/2019 2:32 PM

    • Are other hospitals providing actual CMS compare data sheets or links to website to view compare data for the required post acute facility? What is the required method from CMS?

      Posted by Angela Wright on 3/5/2020 4:28 PM

    • Is this rule in effect now? I know it said Nov 2019 but are critical access hospitals already doing this and if so, how, are they providing this information.

      Posted by Liz on 3/23/2020 1:58 PM

    • Can a doctor order an inpatient physical therapy evaluation after a patient has been discharged from the hospital but is still in the building? To clarify, the doctor has discharged the patient to go home but wants a PT to see the patient before they go home.

      Posted by Sal on 5/9/2020 3:01 PM

    • @Angela: 1. For information on compare data compiled by providers, see the final rule, page 51844-51845: https://www.govinfo.gov/content/pkg/FR-2019-09-30/pdf/2019-20732.pdf, Please contact us at advocacy@apta.org if you'd like to discuss further.

      Posted by APTA staff on 5/12/2020 6:08 AM

    • @Liz: 2. These regulations are effective on November 29, 2019. This rule finalizes certain provisions of proposed rules from November 2015 and June 2016. The critical access hospital’s discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). For the full section of the discharge planning rule as it applies to CAHs, please see page 51884, §485.642 Condition of participation: Discharge planning, here: https://www.govinfo.gov/content/pkg/FR-2019-09-30/pdf/2019-20732.pdf

      Posted by APTA staff on 5/12/2020 6:08 AM

    • @Sal: Yes, the PT can and often does assess the patient before they are discharged. Whether that evaluation is separately payable would depend on the payer policy.

      Posted by APTA staff on 5/12/2020 6:09 AM

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