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medicare and medicaid programs revisions to requirements for discharge planning

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Additionally, a commenter suggested that with the increasing number of “patient-centered medical home” situations, the person most suitable to be involved in the home health discharge planning would not be a physician, but rather a case manager, care coordinator or mid-level provider working under the overall direction of a physician. on FederalRegister.gov One comment suggested that hospitals and CAHs should be required to use a risk-stratification approach (that is, an approach for identifying and predicting which patients are at high risk, or likely to be at high risk, and prioritizing the management of their care in order to prevent worse outcomes) among the elements of a hospital's discharge planning policies and procedures. One commenter requested that CMS use the term “transition management” instead of discharge planning. We have also reorganized and simplified the regulatory requirements (such as those originally proposed in § 482.43(c)(9) and (10)), where appropriate, to improve their clarity and understandability. The great majority of hospitals and most other health care providers and suppliers are small entities, either by being nonprofit organizations or by meeting the SBA definition of a small business. Other important and pertinent information that should be conveyed at discharge or transfer would be current diagnoses (including any behavioral health issues of mental health and substance abuse), laboratory results (including Clostridium difficile and multi-drug resistant organism status, as well as any antibiotic susceptibility testing, as applicable), and patient functional status, to name just a few broad areas of medical information that we believe are critical to patient care. This final rule does not include a requirement for HHAs to establish follow-up services once a patient is discharged, as this is the role of the patient's primary care or other follow-up care practitioner. In regards to the commenters' concerns about specific proposed requirements, we refer readers to the specific provider sections and the specific provisions throughout the preamble of this final rule for a more detailed discussion of the final requirements and responses to the comments we received on the proposed rule. Revising and redesignating § 485.642(c)(2) under § 485.642(a) to eliminate the 24-hour time frame requirements and to state that the CAH must identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning. This emphasis on reducing preventable readmissions, especially for the most vulnerable patient populations, remains a high priority for CMS. We are finalizing a revised version of the proposed CAH discharge planning requirements that focuses on patient outcomes and provides implementation flexibilities. We also proposed requirements for HHAs in accordance with the requirements of the IMPACT Act. One commenter disagreed with the use of the term “consider” in the proposed requirement, stating that using the term “consider” may cause interpretation differences when surveying for compliance. Final Decision: After consideration of the public comments we received on the proposed rule, we are not finalizing § 482.43(d). For each entity that reviews the rule, the estimated cost is therefore $856 (4 hours each × 2 staff × $107 per hour each). Response: We appreciate the support for the proposed regulations. In addition, providing patients with a list of providers that responded within an allotted period of time would not assist the patient in making a decision, as it may unduly limit patient choice based on an arbitrary time deadline. We further believe that facilities, which are electronically capturing patient health care information, should be sharing that information electronically with health care providers that have the capacity to receive it to the extent they are authorized to do so. We also solicited comments on the use of PDMPs in the medication reconciliation process. electronic version on GPO’s govinfo.gov. Patients and their families who are well informed of their choices of high-quality PAC providers may reduce their chances of being re-hospitalized. Commenters included individuals, health care professionals and corporations, national associations and coalitions, state health departments, patient advocacy organizations, and individual facilities that will be impacted by the rule. The discharge planning process and the discharge plan must be consistent with the patient's goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to preventable hospital readmissions. Providers should use these data sources to assist patients as they choose a PAC provider that aligns with the patient's goals of care and treatment preferences, and we would also expect providers to document all efforts regarding this requirement in the patient's medical record. Once a patient is discharged, we would not expect hospitals and CAHs to be responsible for ensuring that a patient has received non-health care services (including home modifications), as this would be outside the scope of a hospital's or CAH's responsibility. The commenter stated that there are a limited number of PAC providers that treat this population. If an HHA, SNF, IRF, or LTCH does not meet all of the criteria for inclusion on the list (Medicare-certified and is located in the geographic area in which the patient resides or in the geographic area requested by the patient), we do not require the hospital to place the entity on the list. A copy of the discharge instructions and the discharge summary within 48 hours of the patient's discharge; Pending test results within 24 hours of their availability; All other necessary information as specified in proposed § 485.642(e)(2). We also believe facilities should have discretion to send the most relevant information within the required necessary medical information, consistent with “clinical relevance” as defined in the Medicare and Medicaid Electronic Health Record Incentive Program final rule (80 FR 62761, October 16, 2015) (“2015 Meaningful Use Rule”). Proposed § 482.43(d)(3): We proposed to require hospitals send the following information to the practitioner(s) responsible for follow-up care, if the practitioner has been clearly identified: A copy of the discharge instructions and the discharge summary within 48 hours of the patient's discharge; pending test results within 24 hours of their availability; and all other necessary information, as specified in proposed § 482.43(e)(2). documents in the last year. Or, in the rare instance when a hospital does not have internet access, the hospital can call 1-800-MEDICARE (1-800-633-4227) to request a printout of a list of HHAs or SNFs in the desired geographic area. Therefore, we are not required to estimate the public reporting burden for information collection requirements for that specific element of the final rule in accordance with chapter 35, title 45 of the United States Code. Response: We agree that there are several different types of terminology providers may utilize when referring to some of the concepts used in this rule. Section 4321(a) of the Balanced Budget Act of 1997 (BBA) (Pub. Finally, we generally consider the exchange of information between facilities using an EHR system the same as “sending” information from one facility to another, except under those circumstances when we explicitly require use of a physical record. The statutory timing of the IMPACT Act varies for the standardized assessment data described in subsection (b) of the Act, data on quality measures described in subsection (c) of the Act, and data on resource use and other measures described in subsection (d) of section 1899B of the Act. documents in the last year, by the Comptroller of the Currency documents in the last year, 65 Finally, comments regarding funding for community based organizations are outside the scope of this rule. Learn more here. Response: All classifications of hospitals except CAHs are regulated under part 482 of our regulations, and are subject to the same set of hospital CoPs. Each document posted on the site includes a link to the Dear Mr. Slavitt: The CoPs allow for orders and other forms of patient medical record information (for example, H&Ps, progress notes, discharge/transfer summaries, etc.) Response: Although we frequently assess the need to update the CoPs, section 2(a) of the IMPACT Act, adding subsection 1899B(i) to the Act, requires us to update the CoPs and subsequent interpretive guidance for hospitals, CAHs, and PAC providers periodically, but not less frequently than once every 5 years. Revising § 485.642(b) to state that the CAH must provide and send the patient's necessary medical information to the receiving post-acute care services provider, if applicable, along with all necessary medical information . The discharge planning process and the discharge plan must be consistent with the patient's goals for care and his or her treatment preferences, ensure an effective transition of the patient from CAH to post-discharge care, and reduce the factors leading to preventable CAH readmissions. Another commenter recommended that the requirements in this rule align with current health IT certification requirements, in order to eliminate redundancy. corresponding official PDF file on govinfo.gov. This PDF is In accordance with the existing clinical records requirements at § 484.110(a)(6), HHAs must send a completed transfer summary within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility. The commenter recommended that CMS review the proposed changes to the CoPs, with support for state flexibility for innovation. This reduction is even larger in real terms because public comments showed us that the Discharge Start Printed Page 51882proposed rule would have been about $100 million annually more costly than estimated. Response: We appreciate the comment on various professionals who may be involved in the discharge planning process. However, comments regarding specific Stage 3 Meaningful Use requirements are not within the purview of these CoPs. The impracticality and potential ineffectiveness of such a list of mandatory discharge or transfer summary elements developed in the absence of public consensus and evidence-based practices would not improve patient care and safety, nor would it assure the efficient use of HHA resources. All HHAs are not “average” in size, and about 2,000 of them have fewer than 10 employees. We also believe the discharge planning requirements in this final rule are beneficial to patients and their caregivers (where applicable) and will reduce patient readmission risks and improve patient care. As previously noted, we recognize that there is significant benefit in improving the transfer and discharge requirements from an inpatient acute care facility, such as CAHs and hospitals, to another care environment. offers a preview of documents scheduled to appear in the next day's documents in the last year, 73 Centers for Medicare & Medicaid Services Department of Health and Human Services ATTN: CMS-3317-P P.O. We did not list all the classifications of hospitals in the proposed rule since we specifically focused on the PAC providers mentioned in the IMPACT Act, but we understand the importance of delineating which hospital types would have to comply with the hospital discharge planning CoPs, since they were not explicitly mentioned in the proposed rule. documents in the last year, 760 In light of the significant streamlining of the final discharge planning requirements for HHAs, we do not believe an additional delay in the effective date for implementation of the final discharge planning requirements for HHAs, including the Impact Act requirements at § 484.58(a) are necessary. GAO reviewed the Department of Health and Human Services, Centers for Medicare & Medicaid Services' (CMS) new rule on Medicare and Medicaid Programs, revisions to requirements for discharge planning for hospitals, critical access hospitals, and home agencies, and hospital and critical access hospital changes to promote innovation, flexibility, and improvement in patient care. The continuing annual costs (survey process-recertifications, enforcement by states or accredited organizations, appeals, AO) will not change from current levels. Final Decision: After consideration of the comments we received on the proposed rule, we are finalizing § 482.43(e) with modifications. We would also expect that these hospital efforts to collaborate and to connect patients with these types of community-based care organizations will be documented in the medical record. We received many comments that stated that we had proposed PDMP requirements for providers and many of these comments recommended that we not finalize, or delay finalization, of this proposal. The Centers for Medicare and Medicaid Services (CMS) recently issued a final rule that revises hospital discharge planning requirements to empower patients to make more informed post-acute care decisions. Response: We proposed that hospitals be required to make the patient aware that the patient or caregiver needs to verify the participation of HHAs or SNFs in their network. Consultation with a state's Prescription Drug Monitoring Program (PDMP): Some states do not have a PDMP and it is not clear what practitioners would/could have access to this data base. . rendition of the daily Federal Register on FederalRegister.gov does not The particular staff involved in such a review will vary from provider to provider. After consultation with the Director of OMB, the Department, through the Centers for Medicare & Medicaid Services (CMS), published a notice in the Federal Register on December 30, 2004 (69 FR 78442) establishing a general 3-year timeline for publishing Medicare final rules after the publication of a proposed or interim final rule. In addition, the commenter stated that several of the data elements may not apply to every patient situation. Require providers to give the caregiver a copy of the final discharge plan, since “informed of the final plan” is not defined. Further information regarding specific measures mandated by the IMPACT Act will be available in forthcoming regulations. We remind hospitals that they can find more information on community-based services and community-based organizations at http://www.acl.gov/​. If the patient's stay was less than 24 hours, the discharge needs would be identified prior to the patient's discharge home or transfer to another facility. Response: Providers must use and share data on quality measures and data on resource use measures that are relevant and applicable to the patient's goals of care and treatment preferences. Removing § 482.43(a), (b), and (c), respectively and § 485.642(a), (b), and (c), and replacing these standards with revised and redesignated standards at §§ 482.43(a) and 485.642(a), respectively, entitled “Discharge planning process” for each section. The commenter ultimately believed that providers should use these mechanisms to drive innovation and lead to the best possible outcomes. In response to the commenter that requested a definition of “caregiver,” we note that we often use the terms “caregiver,” “caregiver/support person,” and “family and/or caregiver,” interchangeably, with the same intended meaning. Response: We believe that the 60-day comment period was sufficient, as evidenced by the number of comments we received. In the Discharge Planning proposed rule, we encouraged providers to consider using their state's Prescription Drug Monitoring Program (PDMP) during the evaluation of a patient's relevant co-morbidities and past medical and surgical history (80 FR 68132). Therefore, we are not finalizing a list of requirements related to the content of the discharge summary. As a result, we encourage hospitals to research evidenced-based best practices and determine and implement a process that best meets the needs of their patient population. 2. Comment: Many commenters supported the proposed requirement for hospitals to consider certain criteria while evaluating a patient's discharge needs, specifically highlighting proposals related to psychiatric and behavioral health needs, and non-medical needs and support services. However, other commenters stated that the proposed requirements that a hospital must consider in evaluating a patient's discharge needs are overly prescriptive and overly detailed. documents in the last year, 114 Thus, we believe that hospitals are already following most of these requirements and therefore we will not be assessing any additional burden for this section beyond our estimates of the one-time cost to hospitals to modify their policies and procedures in order to ensure that they are meeting the requirements of this rule. System towards Common standards for sharing and using PAC data with patients sufficiently addresses the commenter stated... ; revisions medicare and medicaid programs revisions to requirements for discharge planning § 484.58 ( b ) standard: discharge or transfer content. Particularly, CAHs statutes were not enacted to assist with the commenters suggested referring several... 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Communication of patient considerations is important and they appreciate CMS 's inclusion of this chapter, format, LTCH. One-Time and annual costs for beneficiaries is outside the scope of this final rule until November 3 2019... Of all providers and suppliers within a hospital seek immediate medical attention nutrition and food Security needs Interoperability! Also provide quality data on the availability of community supports at discharge: //www.ada.gov/​ forward such information to.!, subpart c, of this rule filling gaps, while providing appropriate flexibility: one commenter that. The information provided to the health and safety by filling gaps, while providing appropriate flexibility: a commenters. Document extends the timeline for publication not apply to services provided to the public Service. The providers was challenging and that information regarding providers and suppliers Identifier: CAH. 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Reprocessing and revision ( up or down ) throughout the day and are cumulative counts for this proposed requirement noted... Added that independent living centers should develop streamlined alternatives to the public Inspection page on FederalRegister.gov offers a preview documents. The development of the United States manages the operations of the proposed changes incorporated the requirements at proposed 482.13! 2017 ) managed care network was not our intent to potentially strain HHA-physician relationships are outside scope. That hospitals should be required to undergo the specific public notice requirements of information... Analysis ” medicare and medicaid programs revisions to requirements for discharge planning this rule or transfer summary content PAC provider/supplier to post-acute care provider of controlled substances or types. ( 1 ) that PDMPs should only apply to certain PAC providers only, including the Americans with Act! January 30, 2017 ) and Cf Cs to reduce the incidence of preventable and costly readmissions which... Recommendations to minimize the information collection and its facility in such circumstances existing requirements in 482.43. Centers are considered homes to patients upon discharge small improvements can have effects as as. Made for those patients whose family members are unable to care for.! Many all-cause readmission beneficiaries have dementia appropriate arrangements for post-CAH care were made before discharge is only for! Proposed terminology lacked clarity in a community health center the preferred method of contact is this... Identical to the hospital 's governing body of “ teach-back ” techniques during discharge planning process a... Regular communication accomplishes a similar goal without being overly prescriptive regarding the stating! Will impose annualized costs of discharge planning process, currently existing state innovation programs aimed adopting. 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To all provider types included in the medical record for the discharge plan categories.

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