Evaluating Your Hospital Eligibility Processes – Part 3 of 3
In Part 1 of our hospital eligibility blog series, we looked at how to evaluate and improve your eligibility process. Part 2 explains the importance of back-end processes and helps you assess whether your back-end staff has the support it needs to succeed. Part 3 dives into discharge planning and why it’s important …
According to the Centers for Disease Control and Prevention, there are more than 35 million hospital discharges in the United States each year. It’s easy to dismiss the discharge process because in most of those cases, the hospital does its job and the patient gets back to his or her life or moves on to another care facility. But unplanned readmission figures tell a different story and invite every hospital to scrutinize its own discharge process.
The cost of unplanned readmissions is estimated at $20-30 billion annually, with nearly one in five Medicare patients readmitted within 30 days after being discharged, according to the American Physical Therapy Association (APTA).
Transitioning from hospital to home or hospital to a post-acute setting is a risky time for a patient – it’s during this time that mistakes can be and are often made. One of the biggest problems, according to WebMD, is a lack of communication between the team taking care of the patient in the hospital and the team that takes over once he or she leaves the hospital. This can result in medical errors that endanger the patient’s health or result in readmissions.
That’s where a good discharge plan comes in. Discharge planning determines what services and level of services the patient will need after discharge and matches the patient to the care site that best fits him or her. A discharge plan is a written document that should detail the following:
- Where and how a patient will get care after discharge
- What the patient and his/her support groups can do to facilitate recovery
- Healthcare issues that might occur in the new care setting
- Medications the patient is using now or will need going into the new setting
- Necessary equipment or supplies needed for day-to-day living
- Resources available to help with costs of care and to manage the patient’s health
A good discharge plan also should identify all potential coverage options before discharge to help create a better plan for the patient’s post-acute care. All this planning should begin at intake or hospitalization. The more patient information that hospitals have on hand, the more accurate and effective the patient’s discharge plan will be.
One goal of discharge planning is to reduce readmission rates, when patients return to the hospital within 30 days after being discharged from their previous hospital stay.
According to a Healthcare Cost and Utilization Project Statistical Brief from the Agency for Healthcare Research and Quality, hospital readmission costs were more costly than initial admission costs for about two-thirds of the most common diagnoses in 2016. The AHRQ found that the average readmission cost for any diagnosis in 2016 was $14,400.
Readmissions are costly for hospitals in more ways than one. Hospitals with high readmission rates likely will see less-than-stellar patient outcomes, and excessive rates also can threaten a hospital’s financial health, especially in a value-based reimbursement environment, according to RevCycle Intelligence. CMS is replacing reimbursement models with fee-for-service models, which increases the financial burden of hospital readmissions, RevCycle Intelligence said.
In addition, the U.S. Affordable Care Act’s Hospital Readmissions Reduction Program (HRRP) allows for hospitals to be hit with financial penalties for excessive readmissions of Medicare patients. HRRP decreased rates by 8% nationally between 2010 and 2015.
CMS penalized more than 2,500 hospitals by more than $564 million in 2017 for excessive 30-day hospital readmission rates.
But readmissions are still a huge cost for U.S. hospitals. According to America’s Health Rankings and The Dartmouth Atlas of Health Care, total annual costs for hospital readmissions within 30 days of discharge in 2011 was $41.3 billion.
Hospital readmissions cost Medicare about $26 billion annually, with about $17 billion spent on avoidable hospital trips after discharge, according to data from the Center for Health Information and Analysis.
Avoidable reasons for hospital readmission include:
- Confusion about prescribed medications, which should be taken and when
- Miscommunication by hospital staff of important info, such as test results, to patient’s primary care doctors
- Improper follow-up care after release
Another way to reduce readmissions is to identify all potential issues, eligibility information and coverage options before discharge to help create the best possible plan for post-acute care for the patient.
Improving the Discharge Process
Discharge planning begins at a patient’s intake – and eligibility data can play a big role in creating a good discharge plan.
If everything is done correctly at intake, a hospital will have collected critical patient information. At intake, providers identify what types of services a patient requires, review coverage options, gather necessary supporting documents and check all the boxes for creating a claim when services are provided. This information will lay the groundwork for a patient’s care plan and forms the basis for the provider’s subsequent reimbursement claims.
Eligibility information paints a picture of the patient’s healthcare status, sets the course for accurate billing, and provides historical data, both about the patient and the patient’s payment history. Eligibility data also can help with orders management, or the receiving, coordinating and following through on doctor’s instructions for patients. Eligibility data also can bring order to the chaos that sometimes occurs at discharge by helping to direct the patient’s next recovery steps.
Fixing the Communication Gap
It’s one thing to collect all the right patient data, but it’s quite another to put it to good use for patients. The discharge process has traditionally been fraught with problems because key patient information is either lacking or is not shared among hospitals, doctors, patients and caregivers. To fix that disconnect, CMS wants hospitals with electronic health record systems (EHRs) to send notifications to doctors when a patient is discharged.
In February 2019, the Office of the National Coordinator for Health Information Technology (ONC) and CMS proposed a new rule to encourage interoperability across the healthcare industry and give patients and caregivers easier access to their personal health information. The proposed regulations would implement part of the 21st Century Cures Act (Cures Act) of 2016, according to Health Affairs.
The proposed rule includes new Medicare Conditions of Participation (CoPs) that will require hospital EHRs to send electronic notifications to post-acute care providers when a patient has been admitted, discharged or transferred to another healthcare facility or provider.
“Electronic patient notifications are a proven tool for improving transitions of care between settings and improving patient safety,” CMS said in a statement.
CMS wants providers to send notifications “at admission and either immediately prior to or at the same time of the patient’s discharge or transfer to licensed and qualified practitioners,” and they should include a patient’s treatment history.
Electronic patient-event notifications from hospitals, or clinical-event notifications, are one type of health information exchange intervention that has been increasingly recognized as an effective and scalable tool for improving care coordination across settings, especially for patients at discharge,” the rule states.
CMS Administrator Seema Verma said the rule would go into effect in 2020 and will benefit patients and providers.
“We think this can lead to reduced costs because you are reducing duplication of tests, and more coordinated care will lead to higher quality and better health outcomes,” she said in a statement.
When the proposed CoPs go into effect, providers – including hospitals and physician assistant, certified (PAC) – will need to implement policies and procedures to comply.
However, the rule allows hospitals to be exempted if their health IT systems aren’t capable. CMS said the requirement would not apply to a hospital that doesn’t have an EMR system with the capacity to generate the basic patient personal or demographic information for patient notifications.
Six individuals who previously served as National Coordinator for Health Information Technology said in an article written for Health Affairs that they “unanimously believe that these rules have the potential to transform how information flows through our health care system, catalyzing broad innovation and engaging and empowering consumers.”
They wrote: “Meaningful exchange of data across disparate health data systems would improve patient care through better-informed clinical decision-making and more coordinated and efficient person-centered care.”
A good discharge plan requires good coordination of patient information. It begins at intake and requires healthcare providers and facilities to collect, manage and communicate patient information on an ongoing basis throughout a patient’s acute care.
When patients and their post-acute caregivers don’t get the information they need upon the patient’s discharge, they won’t be able to provide the proper post-discharge care. This leaves patients at risk for serious complications and increases their chances of making a return trip to the hospital.
5 Ways to Improve Your Discharge Planning
- Implement a written policy and procedures for discharge planning.
- Create a written discharge plan for every patient.
- Discharge planning should begin at admission/intake.
- Send a notice to the patient’s doctor when he or she is discharged.
- Use CMS’ Hospital Planning Discharge Worksheet.
How eSolutions Can Help
eSolutions’ tools quickly and easily connect to Medicare FISS/DDE and provide the best solution in the industry to submit and manage your hospital’s Medicare claims. With our Medicare eligibility tool, there’s no need to manually check eligibility in HIQA.
For more information on our eligibility products, click here. Trust eSolutions to provide the best tools for checking eligibility verification.