January 4, 2016
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
P.O. Box 8016
Baltimore, MD 21244-8016
RE: File Code CMS—3317—P
Proposed Rulemaking: Medicare and Medicaid Programs Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies
Dear Acting Administrator Slavitt:
On behalf of The Hospital & Healthsystem Association of Pennsylvania (HAP), which represents approximately 240 member institutions, we appreciate the opportunity to comment about file code CMS-3317-P, the Centers for Medicare & Medicaid Services’ (CMS) proposed rule to revise the discharge planning requirements that hospitals, long-term care hospitals, inpatient rehabilitation facilities, critical access hospitals, and home health agencies must meet to participate in the Medicare and Medicaid programs.
HAP’s member hospitals and health systems provide services across the continuum of care. In addition to acute care facilities, HAP members include rehabilitation hospitals, behavioral health and long-term care providers, hospice providers, and trauma facilities.
CMS indicates that the proposed changes to the discharge planning requirements will help to reduce avoidable hospital readmissions and patient complications, as well as strengthen patient safety. The proposed changes also will help to implement the discharge planning requirements outlined in the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). The proposed rule also emphasizes patient and caregiver engagement throughout the discharge planning process.
HAP agrees that patients and their caregivers should be meaningfully involved in the discharge planning process as the patient transitions from one care setting to another. Our members are actively working to adopt practices that identify patient needs, ensure appropriate transitions, and reduce readmissions.
With regard to CMS’ proposed rule, HAP wishes to offer the following comments:
In the proposed rule, CMS is requiring the creation of discharge plans for a whole host of patients, including all inpatients and some outpatients, in hospitals and critical access hospitals. The proposed discharge evaluation process would consider the patient’s diagnosis, comorbidities, anticipated ongoing care needs, readmissions risk, patient access to non-health care services, relevant psychosocial history, communications needs, and patient goals and treatment preferences. The process also is intended to prepare patients and their caregivers to be engaged in the planning for the post-discharge care.
CMS suggests in the rule that the discharge plan should be tailored to the unique goals, preferences, and needs of the patient; CMS does not expect every patient to need a comprehensive discharge plan. HAP encourages CMS to provide flexibility to tailor the discharge planning activities to the needs of each patient.
Documentation within 24 Hours
CMS requires the documentation of the patient’s discharge needs within 24 hours after admission/registration. While HAP fully embraces a timely, ongoing discharge planning process, we urge CMS to eliminate the specific 24-hour requirement. This may require a manual or electronic alteration to the patient’s medical record to capture this information on admission. While initiating discharge planning on admission may be valuable as hospitals try to reduce inpatient and observation length of stays, this may pose a challenge for same-day surgery patients. HAP questions whether CMS would deem that the requirement was met if the discharge planning process was completed during the patient’s pre-admission testing, which is performed in the outpatient setting. Finally, CMS states the discharge planning process must not "unduly or unnecessarily" delay a patient’s discharge. HAP seeks recognition that circumstances may arise that reasonably postpone a patient’s discharge, such as coordination with social service agencies and awaiting an appropriate placement.
Participation of Caregivers
Currently, legislation has been introduced in Pennsylvania that provides guidance to hospitals to ensure that a patient’s caregiver has the necessary information and instruction to care for the patient following discharge. The proposed Pennsylvania Caregiver Advise, Record, Enable Act (CARE Act) seeks to engage family members and other caregivers in the health care process by facilitating the provision of key information during the discharge process.
Given significant work at the state level to involve patient caregivers and support persons, HAP encourages CMS to provide flexibility in the final rule with respect to caregiver participation in the discharge process.
Post-Discharge Follow-up Process
In the proposed rule, CMS is requiring the establishment of a post-discharge follow-up process for patients discharged to home. CMS defers to hospitals and Critical Access Hospital’s in determining how best to meet the needs of their patient population. HAP supports the approach of CMS to provide flexibility for hospitals to determine the mechanism, timing, and scope of the follow-up.
Discharge to Home
CMS is proposing that discharge instructions be provided to patients and caregivers as well as to any post-acute provider. This represents a process change as, historically, CMS did not necessarily include post-acute providers relative to providing discharge instructions in their disease specific core measures. Communication and handoff of care is a patient safety issue and HAP supports the provision of information to caregivers and post-acute providers at the time of discharge.
Prescription Drug Monitoring Programs (PDMPs)
CMS is requesting comment about whether providers, in evaluating patient discharge needs, should be required to consult with their state’s PDMP to review a patient’s risk of non-medical use of controlled substances and substance use disorders. Additionally, CMS is requesting comment about whether PDMPs should be used in the medication reconciliation process.
Pennsylvania’s PDMP is intended to provide data to health care professionals to enable them to make more informed decisions about prescribing and dispensing monitored prescription drugs to their patients or potential patients.
Pennsylvania’s legislature passed a new law, Act 191 of 2014, which requires monitoring Schedule II through Schedule V controlled substances. The Pennsylvania Department of Health now is responsible for the development and the day-to-day operation of the new system.
Once the new PDMP is fully operationalized, dispensers are required to submit record of all dispensed Schedule II, III, IV, and V controlled substances to the system within 72 hours of dispensing.
The Pennsylvania Office of the Attorney General (OAG) operated the former PDMP. The PDMP within the OAG required the reporting of Schedule II controlled substances only.
Currently, most facilities in Pennsylvania are not consulting with the PDMP review on all patients. Establishing a requirement to consult with the state PDMP when evaluating a patient’s discharge needs and during the medication reconciliation process may pose additional responsibilities that would require the addition of staff in a facility’s pharmacy department. HAP recommends that, if CMS considers imposing this requirement, it consider instituting this requirement only for high-risk patient populations.
In the proposed rule, CMS outlines its desire for hospitals and critical access hospitals to improve their focus on psychiatric and behavioral health patients. CMS’ expectations include that hospitals and critical access hospitals must identify the types of services needed upon discharge; identify organizations offering community services; and arrange for the development and implementation of a specific psychiatric discharge plan for the patient as part of the patient’s overall discharge plan. This would include coordination with the patient for referral for post-acute psychiatric or behavioral health care services.
HAP supports this concept. Our acute care providers are working to fully integrate behavioral and physical health care. However, facilities and communities might not currently have the capacity to provide these behavioral health services. HAP cautions CMS that it needs to consider the existing shortages in behavioral health care resources and services. For example, there currently is a shortage of psychiatrists in Pennsylvania. The identification and recruitment of such physicians is particularly difficult in rural areas. HAP recommends that CMS seek more stakeholder input regarding the access and allocation of qualified staff.
HAP urges CMS to establish an effective date that is two years from the date of the final rule in order to provide sufficient time for hospitals to implement the new requirements. Implementation will require the investment of significant time and resources, including allocation of additional staffing, training of staff, changes to workflow and procedures, and alterations to electronic health record systems that will have to be incorporated by vendors.
HAP appreciates the opportunity to submit these comments to CMS’ proposed rulemaking. If you have any questions regarding HAP’s comments, please feel free to contact me at (717) 561-5525, or Mary Marshall, HAP’s director, workforce and professional services, at (717) 561-5312.
Senior Vice President
Health Economics and Ploicy