The new discharge planning rule from the Centers for Medicare & Medicaid Services (CMS) went into effect late November. The final rule is intended to empower patients and enhance their rights, in addition to utilizing technology to ensure seamless transitions across the care continuum. Although several key provisions, such as the mandate to send a copy of discharge instructions and the discharge summary within 48 hours of the patient’s discharge, were omitted from the final rule, there is much retained to incent positive advancements in patient care.
Whenever entities are faced with new regulations, there are numerous approaches to compliance. Certainly existing processes, system resources, and unique environments factor into any decision. However, while some health systems may be able to meet the letter of the law with minimal changes, embracing the spirit of the rule presents an opportunity to maximize shared decision making and optimize the value of cross-cutting technology, both within the hospital care setting and during transitions of care.
In the Hospital
One mechanism for a patient to qualify for discharge planning evaluation is the “request of the patient, patient’s representative or patient’s physician.” Seemingly simple, but a laudatory way to acknowledge the patient can participate in the process from its onset. Hospitals are also required to take patient preferences into account.
The discharge planning process, particularly when a patient is considering which facility to transition to, often comes after a short and unexpected hospital stay. For patients, this heightens vulnerability, and lowers health literacy and communication capabilities. Identifying that the present hospital stay may have influenced patient preferences, while taking into account a more holistic view of that individual’s goals, is key for systems maximizing shared decision making.
Previously-expressed patient preferences may be stored in a POLST form or in encounter summaries housed within the hospital’s electronic health record (EHR). Preferences may also be more easily identified if the discharge planner can access information from across the care continuum. Collective’s software allows for these preferences to be aggregated and stored in a variety of ways. Knowing a patient’s encounter history enables a discussion around whether a patient prefers to return to a facility he or she has gone to in the past.
Additionally, care insights can be added by any member of the care team and highlight individual details that may not be captured in a standard EHR—such as a patient’s housing history, the out-of-state adult child who can help coordinate care, or the fact that a patient is no longer able to drive, so any discharge location should bear in mind the limitations of public transportation.
Preferences are also driven by the resources one has available. Collective Flags can be applied by a patient’s accountable care organization (ACO) or health plan and may indicate various information used to influence the discharge plan. For example, knowing that a patient has medical meal benefits available to them once they return home helps the discharge planner discuss the full spectrum of possibilities with a patient to truly ascertain their preferences.
The final rule removed the burden of discharge planning evaluation for all patients, instead requiring it for those “likely to have adverse health consequences.” There is no question that the expertise of a provider and their years of training lend to the value of a qualitative approach for such identification.
However, relying solely on such an approach isn’t likely to create the optimal patient evaluation panel for two key reasons:
- Patients who are part of this at-risk population are likely to be missed, due to factors outside of the confines of the current hospitalization. This may be due to their fragmented records that make it difficult for a provider to appropriately ascertain the full continuum and complexity of their needs.
- A myriad of biases and heuristics are at play when systems rely entirely on qualitative inputs. While asking a patient about their preferences is important, those who do ask for more attention may get identified instead of those who are reticent to engage independently, but who would benefit more discharge planning.
A quantitative approach—with various inputs from outside the system that can take into account what is happening within the existing stay—is an optimal application of technology that is not mandated, but entirely complementary to the final rule. Collective’s real-time readmission risk scores apply cutting-edge machine learning techniques to information on a patient’s comorbidities, care access patterns, social determinant information, and what is transpiring in the present stay. This information gives providers a way to identify patients likely to have adverse health consequences that are serious enough to return them to the hospital.
At the Point of Transition
The same two-pronged, patient-centric, and technologically-enabled approach is present with regards to discharge plan transfer. Given a recent study finding only 52 percent of patients had been given appropriate home-care information upon discharge, patients having the ability to access their own data is empowering.
However, while patients and caregivers benefit from more information, it is often the case that patients are requesting this data to take to another provider. While providers can always request the information from a hospital, there is no guarantee that manual mechanisms succeed in getting that data to the provider by the time of patient interaction. Collective’s Care Team information can aid in ameliorating this challenge for patients by helping hospitals identify which providers are likely to need the information a patient is requesting.
While the rights of a patient to access their own information is commendable, the burden on patients to be the conduit of that data is problematic. Understanding what occurred during the patient’s stay is key for providers managing the patient transition. While hospitals must have infrastructure to comply with Medicare regulations to complete and share discharge summaries, it is even better when the rule inspires them to go above and beyond.
While the current regulations did not minimize the timeframe of 30 days, the flexibility to focus on prioritized patients should encourage the transference of these high-priority discharge summaries sooner than those for patients with a more routine stay. Collective’s CCD functionality is able to attach a discharge summary to a patient, and follow that patient wherever they transition. This allows all downstream providers to see the full clinical history of a patient’s course of care from hospital to post-acute care, home health, and primary care—without the need for each entity to fulfill requests multiple times.
Director of Product
Wylie van den Akker
Chief Information Officer