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Getting Transitions In Care Right: Two Agendas For Change



September 3rd, 2013

Big changes in health care make headlines. Except when they slip by unnoticed.  A memorandum earlier this year from CMS’s Center for Clinical Standards and Quality/Survey & Certification Group to state survey agency directors fits this category.  As if the agency’s title weren’t wordy enough, the subject of the memo, issued on May 17, would hardly excite the average reader, even one familiar with health policy: “Revision to State Operations Manual (SOM), Hospital Appendix A—Interpretive Guidelines for 42 CFR 482.43, Discharge Planning.”

The contents of the 39-page memo, however, are what count. The specificity and comprehensiveness of the guidelines have elevated the standards for discharge planning under the Conditions of Participation in Medicare and Medicaid from a familiar but often undervalued set of activities to a major responsibility that surveyors will review for compliance.

The revised guidelines set out clear expectations for hospitals to take discharge planning seriously by,  among other actions, assigning trained professionals to the task, involving patients and families (or “representatives” or “support persons”) at every stage, and ensuring that appropriate training and referrals to community services have been completed. The guidelines also emphasize that hospitals must know the capabilities and capacities of post-discharge facilities and communicate effectively with them. When implemented by hospitals and monitored by state survey agencies, these changes will go a long way toward improving transitions in care for patients and their family caregivers and reducing hospital readmissions. Cost savings should follow.

An Action Agenda For Better Transitions In Care

In an unplanned but fortuitous coincidence of timing, on May 14 the United Hospital Fund issued “Transitions in Care 2.0: An Action Agenda.”  Like the CMS memo, which acknowledged recent research on transitions in care as the source for many of its revisions, the Fund’s Action Agenda drew on two decades of experience with care transitions carried out by the Fund and leaders of national transitional care programs.

The basic elements of “Transitions in Care 2.0” are: identification of family caregiver(s) and a guided self-assessment of their needs for training and support; discussions with the family caregivers about the patient’s condition and a review of post-discharge options; preparing family caregivers for transitions and providing training on identified tasks; and assisting the patient and family in identifying appropriate community health services and other resources. To put these activities into routine practice, the Action Agenda lays out a series of ten recommendations for changes that need to be made, many by health care providers, but also by payers, regulators, accreditation organizations, and educators.

CMS Adds Specificity To Its Standards

The Action Agenda draws on both the CMS Conditions of Participation and hospital standards set by The Joint Commission.  These requirements have been given new weight by the CMS guidelines, which add specificity and accountability.  Each standard is accompanied by extensive commentary and advice to surveyors about actions to take in reviewing the hospital’s compliance, including chart reviews and interviews with patients and families.  An example of the guidance about §482.43 (c) (3) and §482.43 (c) (5) on the hospital’s obligation to arrange for the initial implementation of the patient’s discharge plan:

The discharge planning process is a collaborative one that must include the participation of the patient and the patient’s informal caregiver or representative, when applicable.  In addition, other family or support persons who will be providing care to the patient after discharge need to be engaged in the process.  Keeping the patient, and when applicable, the patient’s representative and other support persons informed throughout the development of the plan is essential for its success. Providing them with information about post-discharge options, what to expect after discharge, and, as applicable, instruction and training in how to provide care is essential. 

Another example echoed the findings in the 2012 AARP/United Hospital Fund study “Home Alone: Family Caregivers Providing Complex Chronic Care.”  Nearly half (46 percent) of all caregivers in a national survey were doing some kind of medical/nursing task in addition to performing personal care and household chores.  Even though the care recipients had multiple contacts with ERs and hospital stays, 66 percent of family caregivers who performed wound care said that it was difficult and “scary.”  Yet only a third said they had received training from a hospital doctor or nurse. The CMS guidelines recognize that complex tasks like wound care require special attention.

Some patients require wound care that exceeds the capabilities of their family or others who act as informal caregivers.  But they may be able to receive sufficient care in the home setting through home health services.

“We Already Do This.”  Probably Not.

One response to the CMS guidelines might be: “We already do this.”  And yet, when 45 teams from hospitals, nursing home rehab programs, home care agencies, and hospices actually mapped their transition processes as part of the Fund’s Transitions in Care–Quality Improvement Collaborative (TC-QuIC), they found many different understandings of what should happen, who should be responsible, and how to introduce improvements.

The first recommendation in the Action Agenda is to map current practice, using the many tools available from the Institute for Healthcare Improvement, the Fund, and others.  The recommendation adds: “This activity should be a component of quality improvement activity stipulated by CMS’s conditions of participation in Medicare and Medicaid.” In fact, the CMS memo refers to the need for a hospital to “reassess its discharge planning process on an ongoing basis.” Surveyors are advised to review hospital policies and procedures at least quarterly to determine whether the discharge planning process is being reassessed.

Making Sure The Changes Are Implemented

It might be tempting for those of us who have been advocating for improved transitions and involvement of family caregivers in planning and implementation to declare victory and move on.  That, of course, is not going to happen.

CMS has taken a major step toward achieving this goal, and can do more as it issues rules in the future.  But the barriers that existed before are still there—time and resources, to be sure, but also attitudes that have become ingrained over years of inadequate discharge planning and a primary goal of reducing length of stay.

Hospitals should move quickly to endorse and implement these guidelines. The guidelines should be more widely disseminated to health care professionals in all settings and patients and family caregivers so that everyone understands what should happen before, during, and after a transition in care.   This is a change in health care policy and practice that should not slip by unnoticed.

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1 Response to “Getting Transitions In Care Right: Two Agendas For Change”

  1. RalphM Says:

    As always the correct training is crucial in these situations and most of the time this is where everything begins to fall apart. All too often training programs are started with good intentions and then the day to day rush means they are not completed or worse still dropped entirely.

    The most common fault however is the lack of training for the people delivering the training to everyone else. 9 times out of 10 the training of new systems and processes is left to a senior manager who firstly has very little experience of these new systems and secondly has never been trained to become a trainer. There are certain skills that all good trainers have mastered and without training the average manager simply can not do a good enough job.

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