The CMS is proposing a massive overhaul of the discharge process for hospitals, rehabilitation facilities and home health agencies. The latter would likely be hardest hit, facing an annual cost of $283 million, the agency says.
Under the proposed rule, providers would be required to develop a discharge plan within 24 hours of a patient's admission or registration, and would have to complete that plan before the patient is discharged home or transferred to another facility.
The change would apply to all inpatients and some outpatients, including patients under observation status; patients who are undergoing surgery or other same-day procedures where anesthesia or moderate sedation is used; and emergency department patients who have been identified by a practitioner as needing a discharge plan.
The proposed rule (PDF), if finalized, would cost providers a total of $454 million in its first year of implementation and $396 million annually after that. Most agencies already follow some of the suggestions outlined in the rule, the CMS said. But home health agencies (HHAs) lag behind on some of the requirements, the agency said.
"Currently, most home health agencies do discharge planning for their patients without a specific requirement for such. With the cost impact on HHAs projected by CMS, we want to be sure that any final discharge planning design reflects existing best practices to minimize cost implications," said William Dombi, executive director of the National Council on Medicaid Home Care, an advocacy group affiliated with the National Association for Home Care & Hospice.
He added that he hoped the CMS would address the added costs in Medicare payment rates.
“CMS is proposing a simple but key change that will make it easier for people to take charge of their own healthcare. If this policy is adopted, individuals will be asked what's most important to them as they choose the next step in their care—whether it is a nursing home or home care,” acting CMS Administrator Andy Slavitt said in a statement. “Policies like this put real meaning behind the words 'consumer-centered health care.' ”
Additional items in the proposed rule require hospitals, critical-access hospitals, and home health agencies to:
- Provide discharge instructions to patients who are discharged home
- Have a medication reconciliation process, with the goal of improving patient safety by enhancing medication management
- For patients transferred to another facility, send specific medical information to that receiving facility
- Establish a post-discharge follow-up process
In addition, patients and their caregivers could directly select a high-quality, post-acute care provider, since hospitals, critical-access hospitals, and home health agencies would be required to use and share such data, including data on quality and resource-use measures, the agency said.
“This rule puts the patient and their caregivers at the center of care delivery,” said Dr. Patrick Conway, deputy administrator and chief medical officer at the CMS, in a statement.
Provider reaction to the rule has been mixed. For instance, the National Association of Long-Term Hospitals supports increased patient participation in the discharge planning process and believes that it results in improved patient outcomes.
However, the organization has concerns about specifics of the proposed rule, such as sharing data with patients on quality measures and resource use measures, and CMS' advice to use data on the Nursing Home Compare and Home Health Compare websites.
“The information on the Nursing Home Compare and Home Health Compare websites (is) not necessarily current,” said Rochelle Zapol, general counsel for the trade group.
“Another concern is that the hospitals may be viewed as steering patients to specific nursing homes or home health agencies based on the quality measures and resource-use measures on these websites in violation of other federal regulatory provisions.”
The American Hospital Association believes the impact of the rule on its members would be minimal as it appears to incorporate many of the routine practices that hospitals are already undertaking to ensure good outcomes, a spokeswoman for the group said.
"We support provisions of the proposed rule on discharge planning requirements that would enhance the transfer process to skilled-nursing care centers, increase the sharing of patient information between skilled-nursing centers and hospitals, and improve patient safety,” said Greg Crist, senior vice president of public affairs for the American Health Care Association, a nursing home trade group.
“We especially appreciate the agency's recognition that social determinants of health can influence whether a patient returns to the hospital soon after discharge—language barriers and healthcare literacy, social support, availability of community services, and others,” said Dr. Bruce Siegel, president and CEO of America's Essential Hospitals, a trade group for safety net hospitals.
The CMS will be taking comments on the rule until Jan. 3.
The agency's proposed rule is a result of the Improving Medicare Post-Acute Care Transformation Act of 2014. The Act requires the CMS to develop and implement quality measures from five quality-measure domains using standardized assessment data that can be analyzed and assessed to facilitate coordinated care and improve outcomes.
