exceptional snf discharge planning
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TRANSCRIPT
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SNF Community Discharge Planning
Skilled Nursing Facilities Often Fail To Meet Discharge Planning
Requirements https://oig.hhs.gov/oei/reports 02/27/2013
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2013 CMS Focus Areas
Safe Community Discharges
Hospital Re-admissions Patient Safety
Antipsychotic Drug Use
Oversight of Poor
Performing Centers
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SNF Discharge Planning Requirements
• Clinical Summary of SNF Stay • Clinical Status at Discharge• Functional Status at Discharge • Information for Next Care Providers • Information for Patient/Family • Post Discharge Plan of Care
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OIG Report to CMS
• 31% did not meet at least 1 of the discharge planning requirements
• 23% lacked post-discharge plans of care• 16% lacked adequate discharge
summaries
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OIG Recommendations to CMS
• Increase regulations on discharge planning• Improve care planning and discharge planning• Hold SNFs that do not meet discharge planning
requirements accountable• Link payments to meeting requirements• Follow up on the SNFs that failed to meet care
planning and discharge planning requirements
CMS agreed with all 5 of the OIG recommendations
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CMS Findings
High Medicare Re-admission Rates
Failed Rehabilitation
Premature Community Discharges
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Inadequate Management of Care Transitions
$25 to $45 billion in wasteful spending in 2011 through avoidable and unnecessary hospital readmissions.” Health Policy Brief September 13, 2012
Hospital Stay
Re-admissions
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SNF to Hospital 30 Day Re-admitsHealth Policy Brief September 13, 2012
Cost in Billions $$0.0
$5.0
$10.0
$15.0
$20.0
$25.0
$30.0
TotalUnnecessary
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Chronic Disease & Care Transitions
Avoidable Readmissions From Community Adverse Drug Events Diabetes Cardiac Disease Congestive Heart Failure Pain Management Pulmonary Conditions Falls
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Poor Care Transitions Poorly managed transitions can diminish health and increase
costs
Failed Discharge
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Poor Transitions What Happens?
Patients • Don’t fully understand disease • Are confused about medications• Don’t understand test results & causes• Do not schedule follow up appointments• Cannot sustain therapy goals in home
Family members Lack proper knowledge to provide support
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Preventing Poor Outcomes Well managed transitions can improve health & decrease costs
Hospital SNF Home
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Prevent Poor Outcomes Problems?
• Limited Home Support • Health Knowledge
Deficit • Noncompliance • Medication Errors • Treatment Errors • Falls, Safety
Solutions!
•Stellar Discharge Planning
•Patient/Family Education
•Disease Self-Management
•Med Management
Training
•Therapy Re-conditioning
•Safety Training
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Exceptional Discharge Planning
Short Term Care
• Skilled Nursing Care assessment, coordination, services
• Recovery stabilization of disease process
• Rehabilitation return of prior function
• Teaching & Training medications, prevention, mgt.
• Discharge Planning coordination of safe transition home
Medicare A Criteria
• Skilled Nursing Services• Observation & Assessment • Skilled Rehabilitation• Care Plan Development
& Management • Teaching & Training
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Exceptional Discharge Planning
Begins Pre-Admission
Nursing Center Liaison Preferred patient discharge location Family and Community Support Patient & Family Education “short term care” 5 -day plan with SNF team before admit Financial data collection
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Exceptional Discharge Planning On Admission Day
Discharge Team Member Meets, greets, educates patient & family Provides both listing of key facility contacts Reviews care planning process/team’s role Lists the components of short-term care Listens to patient concerns
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Exceptional Discharge Planning Day Two Interdisciplinary Team Meeting
Pain evaluated, plan in place, reviewed with team Diagnoses, medications, treatments confirmed ADLs verified with nursing & therapy Financial data, days available, authorizations Preferred discharge location & support reviewed Community Discharge Plan developed
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Exceptional Discharge Planning
Day Three Discharge Team Meeting Needed discharge level of function established Skilled Care plans in place {Nursing/Therapy} Skilled Observation & Assessment orders in place Discharge educational needs determined Discharge Readiness Form Initiated Goal setting call or meeting scheduled meeting prior to day seven
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Exceptional Discharge Planning
Daily {M-F} Interdisciplinary Team Meetings
Telephone orders reviewed – skilled patients Projected RUG and current minutes to date Late Loss ADLs reviewed & verified {corrected prn} Discharge barriers reviewed Care & treatment refusals reviewed Potential COTs reviewed
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Exceptional Discharge Planning
Weekly Interdisciplinary Team Meeting IDT Summary completed & signed Weekly Discharge Readiness Form Updated Discharge Team Member Patient Follow Up Current & Projected RUG/ARD reviewed Estimated discharge date & function noted
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Exceptional Discharge Planning
5-7 Days Prior To Community Discharge Interdisciplinary Team Meeting Establish Discharge Readiness Care Plan Consider Restorative Services Begin Discharge Transition Care • Patient has written schedule – transports self to therapies • Patient demonstrates self-care teach-back as able• Patient/family complete medication management program • Patient/family complete discharge checklist with nurse• Follow up appointments scheduled & noted • Emergency numbers are reviewed
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Exceptional Discharge Planning
Day of Discharge Nursing & Discharge Team Member Final medication reconciliation 5 day supply of medications Equipment in place Listing of important numbers for follow up Schedule of follow up appointments Caregiver schedules for first visits
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Exceptional Discharge Planning
Day of Discharge Discharge Team Member
Completes physician follow up summary Mails physician follow up summary Schedules 3 day follow up call
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Exceptional Discharge Planning
Post-Community Discharge
3 day follow-up call – discharge team member 14 day follow – up survey – admission staff
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Safe Community Discharges
Sustainable Outcomes
Medication Management
Disease Mgt Education