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No increase in appeals reported with new IM rules
Proactive discharge planning good prevention
Despite fears that issuing the new Important Message from Medicare regulations would result in a spate of patients appealing their discharge, hospital case managers report that appeals have not increased and that the requirement for issuing the notice within 48 hours of discharge actually helps staff focus on the discharge plan.
"When hospitals have a workable discharge plan that they started developing when the patient was admitted, or shortly thereafter, patients are not as likely to appeal," says Jackie Birmingham, RN, MS, vice president of professional services at Curaspan Inc., a Newton, MA, health care technology firm.
"The family is going to be more comfortable with the discharge plan if you plan ahead. If the case managers make sure that patients are aware that they will have a discharge plan when they leave the hospital and that the next caretaker will know everything they need to know about the patient, patients won't be included to question the discharge, which may lead to an appeal. Patients who do question their discharge should be rare," Birmingham says.
The purpose of the requirement is to reinforce what hospitals have been telling patients about their rights to appeal for years, Birmingham says.
"Now the hospital is telling the Medicare beneficiary about their right to discharge planning and the right to appeal should make the patient feel that the timing or circumstance of his or her discharge is not satisfactory," she says, adding, "I never expected hospitals to get so overwhelmed with the process."
The most important part of the Centers for Medicare & Medicaid Services' revision of the Notification of Discharge Rights using the Important Message from Medicare is that the hospital is forced to look at how the message about discharge is delivered.
"It's really more about the message to patients than it is about the written notice. Patients deserve to be notified about pending discharges. This apparently wasn't being done and a lawsuit was filed that resulted in the new regulations. Now patients are getting the message," she says.
When nurses or case managers give patients the second notice of their discharge appeal rights at New York Hospital Queens, they find out if the patient has any issues or concerns about the discharge and work to resolve them in advance, says Caroline Keane, RN, MSN, ANP, CCM, director of case management and social work for the private nonprofit hospital in downtown Flushing.
"If you tell patients they are being discharged at the eleventh hour, they're overwhelmed and their first instinct is to appeal. If you're having a conversation with a patient about a pending discharge a day or two in advance, they're less apt to appeal it. It's actually in everybody's best interest that it's done this way. It's helping us take better care of the patient in the long run," Keane says.
The best way to prevent an appeal is to be proactive with the discharge and get the family involved in discharge planning from the start, adds Roxana Ballinger, RN, CCM, director of care management at Chesapeake Regional Medical Center in Virginia.
"When patients are admitted, we speak to the family and give them an estimated discharge date so they have an idea of when they're going home or to another level of care. Normally, if patients or family members have a problem with a pending discharge, the case manager knows about it and 90% of the time, we can work out their concerns before a formal appeal is filed," Ballinger says.
Many of the reasons that patients file an appeal of their discharge can be tied to the lack of availability of post-discharge services, Birmingham says.
"If hospitals give patients a choice of post- discharge services in a structured manner, it would increase patient satisfaction scores and diminish appeals," she says.
"The problems arise when hospitals give patients a choice of post-acute services, as required by CMS, but the patient's choice is not available," says Birmingham.
Birmingham describes the following scenario:
The patient chooses a nursing home from a list provided by the hospital. The case manager calls and finds out there is no bed available, then goes back and tells the patient. The same thing happens with the patient's second choice. "This goes back and forth and the patient begins to become very frustrated. The patient then decides to appeal and stay until a bed is available at the nursing home he wants," she adds.
Rather than giving patients a long list of choices, Birmingham advises discharge planners to find the providers that do have beds available and are appropriate for the particular patient. Then give the patient and family members a short list of facilities that are appropriate and have beds available from which to choose.
CMS agrees with that approach, she points out. In the Aug. 11, 2004, Federal Register, in the final rule for the hospital inpatient prospective payment system for 2005, in the section on hospital conditions for participation for discharge planning, CMS agreed with a comment that giving patients a comprehensive list of skilled nursing facilities would be overwhelming and confusing for patients and family members, particularly since nursing home placement is usually driven by availability of beds.
"We would not expect that the patient be given an exhaustive list of SNFs with no beds available. The intent is to provide patients and their families with information in order to make informed decisions. As the discharge planner identifies which SNFs have available beds, this information should be shared with the patient and the patient's family," CMS said.
"It's so much more compassionate if the case manager sorts through what's best for the patient and what's available, then gives the patient a list of those facilities that have beds and meet their needs," Birmingham says.
Don't search based only on bed availability, she advises. "An empty bed in an SNF might not be one that can provide the necessary services for the patient. The bed must not only be empty; the facility must be appropriate for the patient," she says.
Offering a choice is critical, not only from a regulatory stance but from a patient-centered, patient-right stance, Birmingham says.
"Offering a real choice — one that is best for the patient, and working with the patient, family, and the patient's physician makes for a better and more satisfactory discharge plan," she explains.
At New York Hospital Queens, the case managers have partnered with nursing to share the responsibility of giving out the Important Message.
"It helps establish an atmosphere of cooperation among the disciplines. People expect the case managers to be the guru of the discharge but we are only part of it. Everybody has to be involved or it doesn't work," Keane says.
The case manager gives out the Important Message if a patient is going to receive post- discharge service or is being discharged to a lower level of care. If the patient is being discharged to home, the nurses distribute it.
"It's a collaborative effort. We collaborate on which patients are going to be ready to go soon, and as soon as we anticipate a discharge, we give out the letter," Keane says.
(For more information, contact Roxana Ballinger RN, CCM, director of care management, at Chesapeake Regional Medical Center, e-mail: email@example.com; Jackie Birmingham, RN, MS, vice president of professional services, Curaspan Inc., e-mail: firstname.lastname@example.org; or Caroline Keane, RN, MSN, ANP, CCM, director of case management and social work, New York Hospital Queens, e-mail: email@example.com.)