To maintain a viable Medicare program in the skilled nursing facility setting, leadership must analyze the admission and discharge process for the Medicare Part A beneficiary. Case management by the Rehabilitation professional is one of the primary factors affecting clinically appropriate stay. Additionally, the Medicare team in the facility must have a standard procedure for handling patients who are admitted with the expectation of returning home after a brief period for Rehabilitation. The discharge process begins once the patient crosses the threshold of the facility.
First and foremost, facilities want to express to the patient and their families the details of the discharge process in the building utilizing the clinical expertise of the whole team. A simple way to accomplish this is to establish a routine discussion regarding the clinical focus for the SNF stay during the admission procedures. The goal of the discussion is to set the stage for the medical team in the facility to clinically manage the discharge. Providing the family and patient with a letter from the Administrator, DON or other facility Director describing the facility philosophy and approach to a goal oriented stay will further support the efforts of the team.
We often encourage facilities to establish a 48–72 hour post admission meeting, to be conducted with the patient and family. During this meeting, the team will clearly outline barriers to discharge and focus on the functional achievements required to ensure a safe discharge home. Daily and weekly meetings should be scheduled and conducted by facility managers, direct care nurses and therapists spurring discussion to reveal the patient’s community living situation and allow for further customized treatment planning.
In February 2013, the OIG Executive Summary specified recommendations to CMS to include the following:
- Strengthening regulations related to care and discharge planning.
- Providing guidance to SNFs to improve care and discharge planning.
- Increasing surveyor efforts to identify SNFs that do not meet care and discharge planning requirements in order to hold SNFs accountable when they fall short.
Harmony (HHI) recommends the establishment of the Discharge Care Plan, framing the resident's exact issues, problems and deficits that have been identified by the Interdisciplinary team as well as the goals of the resident and family. The team should then outline what the resident and the Interdisciplinary team need to accomplish in order for the patient to return home or to the least restrictive environment. The Care Plan should contain specific interventions such as medication management, disease management, home evaluation, follow up appointments, etc. and the discipline responsible for addressing and ensuring timely completion of the interventions.
It is also highly recommended that the Discharge Planning team maintain current lists of locally available housing resources including assisted living, independent senior and subsidized housing. Information for supportive community services such as PACE, homecare, companion care, adult day care, home monitoring and meal, grocery, medication delivery programs to assist in a more coordinated discharge process are also great to have on hand and readily available.