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ABSTRACT
Purpose/objective: To describe steps in offering a patient a choice of post-acute care providers during the discharge planning process that reflects the case management principles and compliance to regulations related to patient's rights to choice.
Primary practice setting(s): Nurses and social workers, particularly those who work in case management or care coordination settings; staff nurses who do discharge planning in acute care settings; and liaison or intake coordinators from post-acute care providers such as skilled nursing facilities and home health agencies who are involved in offering choice to patients during the discharge process; payer-based case managers, particularly those in Medicare Advantage plans.
Findings/conclusion: Patient choice is a right, including during the discharge planning process. Offering choice of available and appropriate options is a case management responsibility not only because of the federal regulations mandating choice but also because it is a reflection of advocacy for patients and families. The work leading up to preparing options from which a patient can choose closely follows the Case Management Standards of Practice (Case Management Society of America, 2002). Follow the process and providing choice becomes a safe and effective part of the transition of care. Note that this is not intended to be legal advice. Consult your own compliance officer for application of the information to your own setting. Every effort has been made to use the most current information.
Implications for care management practice:
1. Patient's right to choice is based on the concept of choosing between appropriate and available options and is dependent on the professional skills and judgment of nurses and social workers, whose responsibilities include the process of discharge planning.
2. Offering patient choice is a function of advocating for patients by ensuring that they receive care needed in the appropriate setting at the appropriate time.
3. More study is needed on the influence of executive cognitive function assessment on patient choice.
4. Investing in software programs that assist in determining availability of appropriate post-acute care providers for individual patients is essential for efficient and safe discharge of patients.
Patient "choice" is different than "consent." The concept of "consent" is granting permission to carry out a selected procedure, as an example. The concept of "choice" is selecting from available and appropriate options. During the discharge planning process, patients have a "right to choice" of post-acute care providers. This article is about "choice."
Mapping a road to patient choice requires a collaborative effort of all involved in the planning for the transition of care from one level to the next. It is one of the processes that is done 100% of the time for patients, regardless of the type or complexity of the discharge plan.
From past experience, and from discussions with large numbers of nurses and social workers, the majority of patients with discharge planning needs have the capacity to participate in making choices. Those who appear to lack the capacity to participate in making choices require concentrated interventions to ensure that this is an accurate determination. A patient who is acutely ill enough to warrant admission to acute care may appear to not be able to participate in decision making, but this may be a factor of his/her clinical condition. If the apparent lack of participation in choices continues, even when the patient is medically cleared, other avenues of providing choice, or taking away their "choice," must be followed. This may include contacting advocates, both personal and legal, or going through the court system. Because each state has a different system for these situations, this article will not include every possible option. The reader is encouraged to work with the social workers, physicians, and legal counsel when situations such as these arise.
The Centers for Medicare & Medicaid (CMS) defines the process of "discharge planning" as a process "in order to ensure a timely and smooth transition to the most appropriate type of and setting for post-hospital or rehabilitative care" (SSA[S] 1861[ee]).
Even the most basic discharge plan involves some level of patient choice and a realization of his/her autonomy. Patients have the right to participate in the care planning process (SSA[S] 1802). Discharge planning is just one of the processes in the "transition" planning concept in that it is a somewhat narrowly focused process that involves movement of the patient from one level to the next, in this case from an acute care setting to a post-acute care setting such as a skilled nursing facility (SNF), home health agency (HHA), hospice, or a self-care setting. Transition planning involves a broader concept of following the patient throughout an episode of healthcare interactions, across the continuum of care.
This article is about choice during the "discharge planning" process. The content primarily addresses the federal regulations of patient choice, which are the minimum standards. Some states may require more restrictive rules for choice, particularly for patients enrolled in a Medicaid program. The reader is encouraged to explore the rules for choice in his/her own state, or for states to which patients may be discharged.
Why an Article on Patient Choice?
The factors of shortened lengths of stay, multiple options for post-acute care providers, resources, or lack of resources, family dynamics, the fact that highly complex care can be provided outside an "acute care setting" all play into the process of discharge planning and, in particular, the process of offering choice to patients among available and appropriate providers of care.
Offering a patient a choice of post-acute care providers during the discharge planning process is an effort in "advocacy." Patients deserve services that are medically necessary, at the right time, and in the right place. They want support in making the right "choice" at a time when they are most vulnerable (Swartz, 2004).
Medical Necessity and Clinical Judgment as Drivers of Patient Choice
There are several references in the Social Security Act (SSA) that relate to a patient's right to choice, with some being very specific about the need to offer choice during the development and implementation of a discharge plan (SSA [S] 1861 (ee), section 6 i, ii, iii). The right to receive appropriate care and to participate in care planning are long-standing rules that have been widely accepted. The hallmark of what choice to offer to patients belongs in the scope of meeting "medical necessity." Medical necessity drives admission and continued stay in a hospital, as much as it drives options given to patients from which to choose.
Determinations of medical necessity must reflect the efficient and cost-effective application of patient care including, but not limited to, diagnostic testing, therapies (including activity restriction, after-care instructions, and prescriptions), disability ratings, procedures, levels of hospital care, extended care, long-term care, hospice care, and home health care. This definition includes the provision of medically necessary services in an appropriate setting, be that hospital, skilled nursing facility (SNF), or home health care. (http://www.acmq.org /; American College of Medical Quality, 2004)
In the discipline of discharge planning, medical necessity, which is the purview of physician practice, must be blended with the application of criteria sets used to review continued stay and the application of clinical judgment. Case managers, who use criteria sets to carry out utilization review for admission and continued stay, must also look at the patient with an eye on the other "clinical" factors that impact where a patient can receive care. Applying criteria sets such as InterQual Guidelines and Milliman Care Guidelines, or "home grown," also known as legacy system, must be used as guidelines, and not policy, on what to look for that can impact the patient's continued stay. When the patient no longer meets criteria for continued stay, as evidenced by using discharge screens in criteria sets, and clinical judgment, he/she should be discharged. The buildup to when that can occur, that is the patient no longer requires an acute level of care, overlaps with the building of a discharge plan that includes post-acute care options and the preparation of a list from which the patient can choose.
Clinical judgment includes those factors that are identified when a case manager uses his/her clinical knowledge, experience, and information. In some situations, such as elective surgery, it is possible to start discharge planning prehospitalization, so the patient has an opportunity for input and knows what to expect; this allows planning for the posthospitalization phase. However, in most situations, this is not always feasible. Then, discharge planning does start at the time of admission, regardless of how the patient was admitted. Starting at admission will ensure that a plan is in place when the patient is no longer at the acute level of care. A well-developed discharge plan can be implemented at a time coinciding with the patient no longer meeting medical necessity for continued stay. The clinical judgment is best applied in collaboration with the physician who determines medical necessity, and case managers who work with all the information to render clinical judgment on functional capacity for discharge. Case managers have the ability to objectively form an opinion about a patient's readiness for discharge, and what the potential post-acute level of care would best meet the continuing care needs of the patient. Case managers need to express those opinions based on assessment of the patient, and knowing the levels and types of post-acute levels of care to which patients can be discharged and the mitigating factors that can be determined by clinical judgement (see Table 1).
 | TABLE 1 |
Discharge Planning From the Emergency Department and Observation Status
Patients discharged from the emergency department or from observation status must be involved in the plan for follow-up care. But, because these two levels of care are considered to be "outpatient" services, the specifics of discharge, admission, or transfer to the next level of care are related to other rules. For patients in the emergency department, the Emergency Medical Treatment and Active Labor Act (EMTALA) rules apply. These rules are generally used to facilitate a discharge to the community, back to the previous setting of care, or for a transfer to a higher level of care such as admission to an inpatient acute care setting. (http://www.cms.hhs.gov/manuals/downloads/som107ap_v_emerg.pdf ). The responsibilities of discharge of patients from the emergency department are based on medical necessity as determined by the physician, proper application of the criteria sets, the clinical judgment of all health professionals involved in the patient's care, and the ongoing needs of the patient.
Discharge from an "outpatient observation" service, formerly referred to as "observation status," is a function of meeting the patient's ongoing needs. The patient has a right to participate in the care plan to the next level of care and the right to be informed of the plan and to participate in choosing among available and appropriate options. "Observation care is a well-defined set of specific, clinically appropriate services that include ongoing short-term treatment, assessment, and reassessment that are provided before a decision can be made regarding whether a patient will require further treatment as an inpatient, or may be safely discharged. Observation status is commonly assigned to patients with unexpectedly prolonged recovery after outpatient surgery, and to patients who present to the emergency department and who then require a significant period of treatment or monitoring before a clinical decision is made concerning their next placement" (http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter08-16.pdf ). The "clinical decision" to admit to inpatient status, transfer, or discharge back to the patient's previous setting is under the responsibility of the medical staff, or person with authority to discharge per state rules and regulations for hospitals.
Patients have a right to participate in the discharge plan, but the requirements of choice and the list are generally applied to discharge from an inpatient status. Being consistent in providing choice by the use of providing a list to patients across all levels of care, including from an emergency department and observation status, is strongly encouraged because it gives evidence of patient choice. The clinical judgement factors outlined in Table 1 also apply to patients being discharged from an emergency department and observation status.
Patient Choice in Pediatric Settings
Although the majority of the content in this article relates to the adult population, the same process of offering choice applies in pediatric settings. In pediatrics, Steps 5 and 6 in the "Choice Map" (below) still apply. However, the assessment of executive function would apply to the parents or guardians of the child. Factors listed in Table 2 can apply across settings.
 | TABLE 2 Functional Status Assessment |
Mapping Patient Choice in Discharge Planning
Figure 1 shows a schematic, or map, to patient choice. The stops along the way are numbered 1 through 12. Each stop has specific case management considerations that are outlined below. Follow the map through these steps:
 | FIGURE 1 Patient choice map. |
1. Patient admitted to "inpatient: status: Once the order is written to admit for inpatient care the patient falls under the conditions of participation for discharge planning.
a. The initial assessment of potential needs provides a baseline from which to plan the move forward. The initial assessment (by nursing, social service, case management, etc.) should be based on the immediate identification of possible need.
b. Discussion of newly admitted patient's status during unit-based rounds can help identify patients early in the admission.
2. Admit from HHA or SNF.
a. If a patient is admitted during an episode of care, either in an SNF, HHA, or hospice, the initial assessment must include the types and levels of services received prior to admission;
b. factors involved in the reason for admission from that level of services; and
c. whether it is anticipated that the patient will return to that same level of care; in this situation, the case manager must also assess whether the patient's bed, or home health service, is still available.
3. Return to HHA, SNF, or hospice:
a. A determination of a patient's preadmission status must be made to assess whether the patient met the maximum potential at that level of care, and whether it will be medically necessary for the patient to return to that level of care.
b. When doing the initial history, the status of the patient's length of time in which he or she was on service at the prior level should be determined. For example, if the patient was receiving Part A (Extended Care Benefit) in the SNF, he/she may be reinstated to that level of care if there are days left and if the care level is still medically necessary.
4. Contact previous care setting staff for information:
a. If it is determined that the patient will return to that level of care, contacting the provider, usually a charge nurse, must be done as early as possible to not only determine the appropriateness of that level of care but also whether that same provider will be involved with the patient after discharge.
b. A patient admitted from an HHA, SNF, or other type of provider must still be given a choice to either return to that provider or to be referred to another provider.
c. "The discharge planning evaluation must include an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital" (SSA[S] 1861 (ee) (b) (4)).
5. Assess patient: On-going medical, nursing, or therapy needs.
a. The types of services and the amount and complexity of the plan of care for post-acute care services must be reviewed by the case manager.
b. Even though some levels of care offer nursing and physical therapy, the number of hours of therapy per day or per week must be taken into consideration when selecting a level of care. The intensity and complexity of the plan plays a significant part in deciding the level of care to which the patient can be discharged.
c. Medical necessity for selecting a post-acute care provider is as important as medical necessity for continued stay; medical necessity drives the level of care to which a patient can be referred for post-acute care.
6. Assess patient's activities of daily living (ADLs), instrumental activities of daily living (IADLs), and executive function (EF) (see Table 2):
a. ADL assessment will be used to determine the patient's therapy and rehabilitation needs. Note that ADL deficits can be supported by adaptive equipment such as walkers or wheelchairs.
b. IADL assessment is used to triage what level of care a patient may be safely discharged. The IADL has great influence on whether a patient can go home.
c. EF plays a significant role in the patient's ability to make safe and reasonable choices and to understand the risks of some decisions that are required. Also referred to as "executive cognitive dysfunction," these are problems in decision-making capacity that may affect the ability of an individual to return home (Cooney, Kennedy, Hawkins, & Balch Hurme, 2004; Kennedy & Smyth, 2008; Schillerstron, Horton, & Royall, 2005).
d. The patient's capacity of self-care and/or other support must be assessed as part of the discharge planning evaluation. Using the three basic assessment categories in Table 2 will help with that assessment.
e. Some patients will require a more in-depth assessment for functional capacity based on the individual characteristics and on-going needs. This is especially true for patients who exhibit an executive cognitive dysfunction (Cooney et al., 2004). In this case, a patient care conference, which may include the patient's physician, social worker, therapists (physical, occupational, respiratory, speech), pharmacists, dietitians, nurses, and clinical nurse specialists, should be carried out to collect assessment information from each professional involved in the patient's care.
7. Determine level of care (see Table 3):
 | TABLE 3 Patient Characteristics and Potential Levels of Care (Sample Levels) |
a. The number of post-acute care options for ongoing needs is many and varied. The distinction between some levels is very narrow and determining where the patient may best be cared for is critical.
b. Whether the patient can go to an acute rehabilitation setting, such as an inpatient rehabilitation facility, to long-term care, to an inpatient or home hospice, to an SNF for rehabilitation, or to home with a referral to an HHA depends on the assessment of the patient (Steps 5 and 6) and the types of services provided by the post-acute care provider.
c. Another source of information for selecting a patient's level of care is to review insurance coverage for post-acute care services. Many, if not most, payers have an extended care benefit. Reviewing the patient's "criteria" for coverage will help guide the selection of possible post-acute care services. For example: a Fee-for-Service Medicare beneficiary requires three consecutive days in acute care before the "Medicare Extended Care Benefit" applies (Birmingham, 2008). This does not mean that the patient does not need extended care services; it just means that the payment source needs to be identified.
d. Be cautious about selecting a level of care for a patient based on payment source. Level of care selection must be based on assessment factors in Steps 5 and 6 and the medical necessity for that specific level of care.
e. The admission criteria for each level of care to which a hospital can discharge a patient must be known by case managers to better identify where a patient can go for post-acute care.
8. Home without services:
a. If a patient is going to be discharged to self-care or to care of a caregiver, to his/her home, a discharge plan is still needed. At a minimum, a patient will need to know where to access follow-up care, such as with his/her primary care physician.
b. Patient education about self-care must be part of the plan. Working with staff nurses or clinical educators on what the patient needs to know about medications, signs and symptoms of impending problems, and where to get care is critical to a safe discharge.
c. Primary care physician may be unaware of the patient's admission. The CM or the patient, if able, should contact the physician prior to discharge.
d. If the patient needs a follow-up with a specialist, availability of that specialist should be determined prior to discharge.
9. Check availability of HHA or SNF: Prepare "The List" (please see the Frequently Asked Questions section).
a. Patients have choice of all types of post-acute care services, durable medical equipment, laboratory, ambulances, pharmacies, and clinics. However, Medicare requires "a list" from which patient can chose only for hospice, SNFs, and HHAs (SSA [S] 1861 (ee) (c) (6)).
b. The list offered is among the appropriate and available providers of care.
c. Appropriate providers of care are those who can meet the identified needs of the patient. For example, a patient may need specialized rehabilitation services that only a few providers have. The list then would include only those specialized services.
d. Availability is also a factor in presenting the list. An empty bed is not always an available bed to the individual patient. There must be a match of patient's needs to providers with an empty bed or available service.
e. Geographic location of HHAs and SNFs depends on where the patient lives or where he/she chooses as a location for discharge.
f. Information to a post-acute care provider to determine availability and appropriateness can be transmitted by using a secure, Health Insurance Portability and Accountability Act (HIPAA)-compliant platform. Some agencies and SNFs are still relying on facsimile or phone calls for transmission of information. The agency will need to have a set of information to make a determination. This transmission of information must occur prior to acceptance, so that the patient's needs can be accurately identified and matched to the services provided by the post-acute care provider (Medicare Learning Network SE0726, 2009).
g. There are Web-based programs that connect hospitals with post-acute care providers for matching of a patient's level of care, specific services, geographic area, and bed availability. Hospital-based case managers are able to find available and appropriate post-acute care providers by accessing the Internet over a secure HIPAA-compliant platform.
h. After matching the level of care, specific clinical needs, and geographic location, the case manager develops a "choice letter" to be shared with patients. The patient choice letter (Figure 2) is an example that may be used as a discussion point. Some important points of constructing a patient choice letter can be found in Table 4.
 | FIGURE 2 Patient choice letter. |
 | TABLE 4 Important Points for Constructing a Patient Choice Letter |
10. Assist the patient to choose from "The List" of options:
a. Taking the list of available and appropriate hospice providers, SNFs, or HHAs, depending on the agreed upon level of care, review the list with the patient. If the patient wants assistance from a family member in selecting from the list, this should be accommodated. Preplanning with the family member is highly recommended so that there will not be a delay in discharge that results from not being able to be in contact with the family.
b. If the patient has demonstrated executive dysfunction behaviors, as mentioned above, it would be especially important to evaluate the impact on the ability to make any type of decision.
c. The number of choices offered to a patient depends on the number of available and appropriate providers. The hospital must offer choice of all matched providers, regardless of the number. However, if there is only one appropriate choice, the patient family must be counseled about the efforts made to find an agency and then counseled about the patient's readiness for discharge and the need to move to a more appropriate level of care. Any concerns about whether or not the patient must take the available and appropriate bed should be discussed with the utilization review committee or representative (SSA[S] 1861 (k); CMS, Beneficiary Notice Initiative, 2006).
d. Asking the patient to choose more than one option at this time helps ensure that, if his/her first choice is no longer available, a second or even third choice may be explored.
e. If the patient is in a Medicare Advantage program, the search for an available post-acute care provider must start with those who have a contract with that payer. However, the patient must still be given the option of going out of the contracted list but must be informed of the possible self-payment requirement.
f. If the hospital has a financial interest in a post-acute care provider that is available and appropriate to the patient, the patient must be informed of that relationship prior to making a choice (SSA[S] 1861(ee) (c)(8)).
I. This information is not only required by the conditions of participation, but it may also be comforting to a patient to know there is a link between the hospital and the post-acute care provider.
II. The hospital cannot steer a patient to an owned agency, but it can offer choice of that agency and, if a patient requests assistance in making the choice, the discharge planner can reiterate the relationship.
III. Frequently discharge planners are reluctant to discuss post-acute care providers that are owned by the hospital for fear of "breaking the rules." The rule of most concern for the discharge planner is that of ensuring patient freedom of choice, rather than to where the patient is referred. Hospitals can refer to their financially related agencies. Just be sure the patient was given a choice and that the patient knows of the relationship.
g. At this time, discharge is likely to be within 48 hours. A copy of the Important Message from Medicare can be delivered and reviewed. This action will alert the patient to a pending discharge and inform him/her of the right to ask for a review of the discharge plan (CMS-Rule 4105 Notice of Discharge Appeal Rights, 2007).
h. Please note that the specific requirement to provide a list of hospice agencies or services is not written in the Conditions of Participation for Discharge Planning by Medicare. In this reference, only HHAs and SNFs are included as needing a list of available service.
I. However, the recommendation for a list of hospice services is included in the State Operations Manual Appendix A-Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, Revision 47, June 5, 2009. The later document is used by surveyors in determining how providers are meeting the standards of care.
II. Regardless of whether or not there is a regulation, giving a list of hospice providers available to the patient is a way of ensuring that patients have a choice in this very important level of care.
III. Also be sure that there is full disclosure of financial arrangements, be it ownership or otherwise, of appropriate and available providers of services, regardless of the type, when giving a patient a list from which to choose.
11. Make the referral to the selected agency:
a. The hospital must transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care (SSA [S] 1861(ee) (d)).
b. Within a predictable time frame, a referral can be made to the agency of choice.
c. Sending preliminary plans to the provider will allow for a smooth transition and an efficient start of care.
d. Clinical information required includes, but is not limited to, the physician's orders and other clinical information. The selection of what clinical information to send is based on the clinical status of the patient and the requirement of the post-acute care provider.
e. Communication back from the agency that the referral has been accepted is critical. Subsequent notification of those agencies that will not be receiving the patient is also important. This will open up the bed or service to another patient. Web-based software programs can automate this process.
12. Discharge the patient:
a. Preparing the patient for the discharge is a collaborative effort. If the hospital policy requires written discharge instructions, this should be facilitated early enough so that the patient will have an opportunity to ask questions for clarification.
b. Medical transportation should be arranged. The patient should be asked whether he/she has a preference for a specific service prior to arranging a transportation service.
Documenting Patient Choice
Patient choice is best documented by following the hospital policy. Some hospitals have a form that patients sign showing they were given a choice; some use verbal communication and narrative documentation. Whatever method is used, at a minimum, it should be documented that the patient was given a "list" of hospice providers, SNFs, or HHAs that are appropriate and available. Also document that the patient was afforded a choice and that they agreed with the final choice or choices. Somewhere in the documentation should be a reference to a "list" of hospice providers, SNFs, or HHAs, a reference to the fact that the patient was informed of any financial arrangements, and that he/she was given a choice.
Whether or not the list is in writing is up to the hospital to determine. A policy and procedure should be written taking into account all of the factors (see SSA [S] 1861(ee) (c) (6)).
How to Maintain the Lists
The list of SNFs and HHAs that are Medicare approved is available at a CMS Compare Web site. There is one Web site dedicated to HHAs (www.medicare.gov/HHcompare/ ) and one specific to nursing homes (www.medicare.gov/NHCompare/home.asp ).
The Nursing Home Compare Web site gives up-to-date information that is searchable by geographic distance, and it also provides a rating of the quality of the facilities.
The Home Health Compare Web site allows you to identify the services the patient will need and the geographic radius that the HHA covers. Information for hospice providers can be found at http://www.cms.hhs.gov/center/hospice.asp .
Please note that names of providers of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) are also available on the Medicare Web site. At the writing of this article, the requirement that DMEPOS providers be "accredited by an approved organization" is in the implementation stage. The reader is encouraged to follow legislation on this topic to be sure that if accreditation is required for providers who serve Medicare patients you will have that information (http://www.cms.hhs.gov/DMEPOSCompetitiveBid/ ).
Regarding the requirement that only HHAs need to "request to be on the list" (SSA [S] 1861(ee) (c) (6)): This requirement predates the Home Health Compare program from CMS, but it is still considered a requirement. In the policy for providing choice, the hospital must address how it identifies HHAs in the geographic area, and how it is known that the HHA requests to be on the list. And finally, reviewing the choice policy with the compliance officer is critical to ensure thorough compliance with the regulations.
Frequently Asked Questions
1. Is it okay to check bed availability before offering a choice?
Yes. The intent of requiring a list is based on offering patients realistic options: "We would not expect that the patient be given an exhaustive list of SNFs with no available beds. The intent is to provide patients and their families with information to make informed decisions. As the discharge planner identifies which SNFs have available beds, this information should be shared with the patient and patient's family" (Federal Register/Vol. 69, No. 154/Wednesday, August 11, 2004/Rules and Regulations Page 49227 Left column:).
2. What is a working definition of "appropriate facilities"?
"Appropriate facilities" refer to facilities that can meet the patient's assessed needs on a postdischarge basis and that comply with federal and state health and safety standards.
http://www.cms.hhs.gov/manuals/Downloads/som107ap_a_hospitals.pdf (page 305)
3. Does the list of choices need to be in writing?
Hospital policy dictates how choice is offered and documented. The policy can require either that it be in writing or verbally shared with the patient and/or family. The most important factor is that, however, the hospital determines choice will be given to patients, it provides that patient choice be given consistently among all patients, and that the choice is irrefutably documented. Some hospitals require a patient to sign a choice list; others require that a narrative note be written that the patient was given a choice of available and appropriate options.
Some software programs now provide an automatic choice letter to be shared with patients that is generated from real-time bed availability. As one example, eDischarge has a functionality that provides for an individualized choice letter that may be printed for the patient and is stored showing the sequential efforts to provide choice of available and appropriate options.
4. What factors go into making up "the list"?
Primary factors in making up the list is first identifying what level of care a patient is determined by the physician as being needed by the patient. The types and levels of post-acute care providers vary greatly but is generally based on the patient's functional status and medical needs, especially if the patient has special needs or the geographic location of the only appropriate facility is out-of-"patient's range."
5. What happens if the patient does not like the available and appropriate choices?
This is a situation in which counseling the patient about the need for discharge to a more appropriate level of care should occur. If the patient continues to refuse to be discharged, the utilization review committee should get involved. The patient may request a review of the discharge, but if the reviewer finds that the discharge is appropriate, the patient should be counseled. In the SSA [S] 1861, standard (c) Discharge Plan, Part (7) reads that "...when possible, respect patient and family preferences when they are expressed." Sometimes it is not possible to afford the patient his/her first choice.
6. Can a physician write an order for a specific post-acute care provider?
Freedom of choice for available and appropriate providers is key. If a physician writes an order for a specific post-acute care provider, it should be based on needs of the patient. The patient must still be given a choice and that should be documented.
7. Can a hospital refer to its own HHA or SNF?
There are two parts to this answer: The first is in standard (c) Discharge Plan, Part (8): "The discharge plan must identify any HHA or SNF to which the patient is referred in which the hospital has a disclosable financial interest, as specified by the Secretary, and any HHA or SNF that has a disclosable financial interest in a hospital under Medicare.
If a written is list used, indicate ownership on writtenlists. If verbal lists are used, tell the patient of ownership and document the disclosure in the medical record. It is okay to refer patients to one's own agency, as long as patient has choice and the agency is appropriate and available."
The second part is standard (c) Discharge Plan (7): "The hospital must not specify or otherwise limit the qualified providers that are available to the patient." Choice is offered to all appropriate and available post-acute care providers. If a patient requests help in sorting through the choices, the hospital-based case manager can counsel the patient about the particular benefits of one SNF or HHA over another and can guide the patient in the decision-making process. This is why the process requires a nurse or social worker (or other qualified individual) to do or supervise the discharge plan (standard (b), number (2)).
References
American College of Medical Quality. (2004, February 2) Policy & definition and application of medical necessity. Retrieved March 26, 2009, from http://www.acmq.org/policies/policy8.pdf [Context Link]
Beneficiary Notice Initiative: The important message from Medicare. (2006). Retrieved October 3, 2009, from http://www.cms.hhs.gov/BNI/Downloads/CMS-4105-F.pdf [Context Link]
Birmingham, J. (2008). Understanding the Medicare "extended care benefit": aka the 3 midnight rule. Professional Case Management, 13(1), 7-18. [Context Link]
Case Management Society of America. (2002). Standards of practice for case management. Little Rock, AR: Author. [Context Link]
Cooney, L. M., Kennedy, G. J., Hawkins, K. A., & Balch Hurme, S. (2004). Who can stay at home? Assessing the capacity to choose to live in the community. Archives of Internal Medicine, 164, 357-360. [Context Link]
Federal Register / Vol. 69, No. 154/Wednesday, August 11, 2004/Rules and Regulations Page: 49227. Retrieved October 3, 2009, from http://www.cms.hhs.gov/quarterlyproviderupdates/downloads/CMS1428F.pdf [Context Link]
Free Choice by Patient Guaranteed: Social Security Act [S] 1802. Retrieved April 1, 2009, from http://www.socialsecurity.gov/OP_Home/ssact/title18/1802.htm [Context Link]
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