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The roles of discharge planners, home health and family in controlling readmissions

Attorney and home care expert Elizabeth C. Hogue shares details about the CoPs that apply to hospitals and discharge planners. This piece encourages the collaboration between discharge planners, family members, and home care providers to ensure that family caregivers understand the challenges for caring for those in the home.

Part 5: Hospital Conditions of Participation for Discharge Planning: Counseling Patients, Family Members, and Other Conditions of Participation (CoP’s) of the Medicare Program for hospitals include CoP’s for discharge planning. This is the fifth in a series of articles about these requirements. Hospitals that do not meet these requirements may lose their certification and ability to receive payments from the Medicare and Medicaid Programs. CoP’s governing discharge planning first state that hospitals must have a discharge planning process that applies to all patients. The Centers for Medicare and Medicaid Services (CMS) says that the CoP’s it develops apply to all patients, not only to patients whose care is paid for by the Medicare and Medicaid Programs. The CoP’s then say that hospitals’ policies and procedures must be specified in writing. Hospital discharge planners should review written policies and procedures required by the CoP’s to make certain that they reflect applicable requirements and current practice. Discharge planners/case managers may be required to demonstrate that they are following their written policies and procedures. At 42 CFR Section 42.43(c)(5), the CoP’s state as follows: “As needed, the patient and family members or interested persons must be counseled to prepare them for post-hospital care.”

If the discharge plan includes home care services, it is important for discharge planners to know that patients must continuously meet the following criteria in order to be appropriate for home care services, regardless of payor source:

  • The patient’s clinical needs can be met at home.
  • The patient can either self-care or there is a paid or voluntary reliable primary caregiver to meet the patient’s needs between home care visits.
  • The patient’s home environment supports home care services.

Patients must be able to self-care or there must be paid or voluntary reliable primary caregivers prepared to meet the needs of patient when agency staff members are not present. Discharge planners should identify reliable caregivers or assist patients and their families to use private duty services so that paid caregivers will serve as patients’ primary caregivers. Specifically, when the discharge plan includes home care services, discharge planners should identify potential primary caregivers if patients cannot care for themselves at home. Realistically speaking, however, about all that discharge planners can tell about potential primary caregivers is that they are vertical and breathing. The competence and reliability of primary caregivers can only be assessed over time.

Nonetheless, it is up to discharge planners to manage the expectations of patients and their families. Although case managers/discharge planners in institutional settings are under such pressure to move patients out of the institution that it is difficult to find the time to explain to patients and their families what must be their role in home care, explanations and information are clearly required by Medicare CoP’s. If discharge planners/case managers do not comply with this requirement, patients may be referred to home care with the expectation that nurses will take care of everything, just as they did in the institution. Unless discharge planners/case managers are counseled as required by the CoP above, this expectation may be further enhanced by a general lack of understanding by many patients and their families about home care. In addition, in the face of illness, it is only human for vulnerable patients and families to want home care providers to simply step in and take care of everything.

Counseling by discharge planners/case managers should include some of the tasks that primary caregivers may be expected to perform that may be repugnant to them. The “big three” such tasks are: wound care, changing diapers, and giving injections. The reliability of primary caregivers may be sorely tested when these tasks are involved. Case managers/discharge planners should be specific about the tasks primary caregivers will be required to perform, especially the three mentioned above.

Both discharge planners/case managers and home care providers continue to be concerned about the difficulties of care transitions and readmissions. Both are more likely to be avoided when the expectations of patients and family members are realistic with regard to home care.

©2013 Elizabeth E. Hogue, Esq. All rights reserved

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