The Partnership for Patients and the Aging Network

Message from the Assistant Secretary for Aging Kathy Greenlee

Today, Health and Human Services Secretary Kathleen Sebelius announced the Partnership for Patients, a new national public-private partnership with the goals of:

* Keeping patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010.  Achieving this goal would mean approximately 1.8 million fewer injuries to patients, with more than 60,000 lives saved over the next three years. 

* Helping patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010. Achieving this goal would mean more than 1.6 million patients will recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge. 

Through the Community-based Care Transition Program, HHS has committed $500 million to community-based organizations partnering with eligible hospitals to help people with Medicare safely transition between settings of care.  Today, community-based organizations and acute care hospitals that partner with community-based organizations can begin submitting applications for this funding.  Applications are being accepted on a rolling basis.  Awards will be made on an ongoing basis as funding permits. In addition, in coordination with stakeholders from across the health care system, the CMS Innovation Center is planning to use up to $500 million in additional funding to test different models of improving patient care and patient engagement and collaboration in order to reduce hospital-acquired conditions and improve care transitions nationwide. 

The aging network – state and local organizations alike -- has a vital role to play in this effort to integrate medical and long-term supports and services and improve care transitions for our clients and their families.  This work also provide an excellent opportunity to integrate other important work you are already doing – including Aging and Disability Resource Centers, benefits outreach and enrollment, caregiving and respite programs, chronic disease self-management and other health promotion/disease prevention programs, and more.  Finally, the partnerships that you build through care transitions work – with hospitals, physician practices, long-term care facilities and other organizations – can also help to position you better for future ACA-related opportunities such as accountable care organizations, health homes, patient-centered medical homes, and more.

Here is how we can work together on this initiative:

* Learn more about the Partnership for Patients and join the partnership by visiting the Partnership website at http://www.healthcare.gov/center/programs/partnership 

* Read our special Affordable Care Act Newsletter which provides you with additional details about the Partnership for Patients and the Community-based Care Transition Program (CCTP).  To access the newsletter, please go to  http://www.aoa.gov/Aging_Statistics/docs/ACA_Enews_P4P_041211.pdf 

* Join us for our next Webinar on Wednesday, April 20, which will offer an overview of the CCTP solicitation, and the opportunities for the aging network that lie within.  (Watch your email for registration details)    

Depression Care in Hospital Helps Cardiac Patients

By Crystal Phend, Senior Staff Writer, MedPage Today

A collaborative program to manage depression among heart patients before hospital discharge appears to ease both mood and cardiac symptoms, researchers found.

A prospective, randomized trial also found that the program improved self-reported adherence to medication and advice on diet, exercise, and stress reduction six months later, Jeff C. Huffman, MD, of Massachusetts General Hospital in Boston, and colleagues, reported in the March issue of Circulation: Cardiovascular Quality and Outcomes.

Such programs have proven successful before, but were only conducted among patients after discharge, the group noted.

Their program showed the feasibility of screening for depression and starting treatment during a "teachable moment" while patients were still in the cardiac unit, Huffman and colleagues explained.

Thus "these results may represent a substantial first step in the systematic treatment of depression in hospitalized cardiac patients, a population for whom depression is independently associated with cardiac morbidity and mortality, and effective therapy remains greatly underrealized," they wrote.

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Intermountain Healthcare's McKay-Dee Hospital Center: Driving Down Readmissions by Caring for Patients the "Right Way" - The Commonwealth Fund

Authors: Sharon Silow-Carroll, M.B.A., M.S.W., and Jennifer N. Edwards, Dr.P.H.

Downloads-Case Study (1745K PDF)

Overview

McKay-Dee Hospital Center in Ogden, Utah, part of the Intermountain Healthcare System, had readmission rates in the lowest 3 percent of hospitals across the nation for all three clinical areas reported to the Centers for Medicare and Medicaid Services (CMS) for the selection period, and its heart failure and pneumonia readmission rates were within the best 1 percent of hospitals reporting (Exhibit 1).
McKay-Dee’s success may be attributed to the following:

• comprehensive quality improvement strategies, supported by extensive, systemwide clinical research and training in evidence-based care;
• standardization of care through "care process models," or clinical protocols, and heavy use of hospitalists;
• information systems designed to monitor quality;
• interdisciplinary care coordination and discharge planning with individualized patient education and scheduling of follow-up appointments before discharge;
• comprehensive identification of heart disease patients for education, post-discharge phone calls, and referral to the outpatient heart failure clinic;
• integration with community providers, both within and outside of Intermountain's network, which provides a continuum of care and helps ensure patients are connected with a medical home; and
• Intermountain's role as a leader in health care delivery and payment innovations, exemplified in its involvement with pilots of bundled payment/accountable care arrangements.

The Intermountain Healthcare System is a highly integrated system with multiple hospitals, primary care practices and clinics, an outpatient heart clinic, home health service, and a renowned clinical research institute. Membership in this system provides clear advantages in terms of shared resources and expertise, and enhanced communication across care settings. Nevertheless, McKay-Dee's experiences provide lessons for other hospitals and systems—even less-integrated entities—that are striving to reduce readmission rates as well as improve outcomes and maximize systemwide efficiencies.

First, McKay-Dee Hospital Center and Intermountain Healthcare operate on the premise that lower readmission rates, better quality measure scores, and financial savings are not the primary focus of their efforts, but rather byproducts of caring for patients correctly. Second, alignment of hospital care with outpatient care improves transitions and health outcomes. Third, it is critical to select and nurture physician leaders who embrace a hospital's quality measurement and reporting philosophy. If other physicians do not respond through medical leadership and incentives, it may be necessary to hold them to a higher level of accountability to encourage their adherence to clinical protocols. Current payment policy that rewards volume rather than clinical outcomes conflicts with some of these desired practices. Over the long term, changes to the incentives in the health care system are needed to align goals across hospitals and other stakeholders.

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This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions' experience that will be helpful in their own efforts to become high performers. Even the best-performing organizations may fall short in some areas or make mistakes—emphasizing the need for systematic approaches to improve quality and prevent harm to patients and staff. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case study series is not an endorsement by the Fund for receipt of health care from the institution.

 

Citation

S. Silow-Carroll and J. N. Edwards, Intermountain Healthcare's McKay-Dee Hospital Center: Driving Down Readmissions by Caring for Patients the "Right Way," The Commonwealth Fund, Feb. 2011.

Memorial Hermann Memorial City Medical Center: Excellence in Heart Attack Care Reduces Readmissions - The Commonwealth Fund

Authors: Aimee Lashbrook, J.D., M.H.S.A., and Jennifer N. Edwards, Dr.P.H.

Downloads

• Case Study (755K PDF)

Overview

Memorial Hermann Memorial City Medical Center (Memorial City) achieved superior readmission rates in two of the three clinical areas reported to the Centers for Medicare and Medicaid Services (CMS). Its readmission rate for patients with acute myocardial infarction (AMI) and pneumonia surpassed the best 10 percent of hospitals in the country for the selection period. Its readmission rate for heart failure was not as strong, outperforming the national average only by a narrow margin. (Exhibit 1)
Memorial City's achievement of low readmission rates for heart attack and pneumonia appears to be related to the Memorial Hermann Healthcare System's efforts to improve quality and patient safety for all patients. At each of the system's hospitals, staff have sought to provide high-quality, safe care consistent with the highest clinical standards and to avoid problems such as infections or falls that can exacerbate patients' underlying health problems. Memorial City, in particular, has achieved exceptionally high standards in AMI care. They also have increased attention to educating and supporting patients and linking patients—even the uninsured—to needed care after discharge, which likely reduces readmissions.

Specifically, the following efforts and patient-focused interventions, which were initiated by the system and implemented at the hospital, seem to contribute to Memorial City's low readmission rates:
Organizational efforts

• Emphasis on quality, with a clear leadership vision that is communicated to all clinical staff and backed up by the commitment of needed resources. The health system aims to "do the right thing the first time."
• Concurrent review of performance on core measures during a patient's stay to monitor achievement of goals, with findings reported to physicians.
• Extensive employee training related to the system's top priorities to make sure everyone is "rowing in the right direction."

Patient-focused interventions

• Planning for discharge begins upon admission, with staff actively educating patients about their disease and connecting patients with a source of ongoing care, even if they lack insurance coverage. The hospital offers a community-based disease management program for uninsured patients with chronic illness.
• Risk-assessment software helps case managers establish the appropriate level of care and assess a patient’s readiness for discharge.
• Pharmacists are located in high-risk units to provide medication education to patients and help simplify home medication regimens.
• Iterative process improvements in AMI care have resulted in a lower door-to-balloon time, which preserves heart muscle, thus reducing complications and the risk of readmission. Memorial City’s average door-to-balloon time is around 65 minutes, compared with the Joint Commission's standard of 90 minutes.

Planning for discharge begins upon admission, with staff actively educating patients about their disease and connecting patients with a source of ongoing care, even if they lack insurance coverage. The hospital offers a community-based disease management program for uninsured patients with chronic illness.

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This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions' experience that will be helpful in their own efforts to become high performers. Even the best-performing organizations may fall short in some areas or make mistakes—emphasizing the need for systematic approaches to improve quality and prevent harm to patients and staff. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case study series is not an endorsement by the Fund for receipt of health care from the institution.

Citation

A. Lashbrook and J. N. Edwards, Memorial Hermann Memorial City Medical Center: Excellence in Heart Attack Care Reduces Readmissions, The Commonwealth Fund, Feb. 2011.

Gap Seen in Readmit Rates by Race, Location

By Michael Smith, North American Correspondent, MedPage Today

Older black patients admitted to hospital for three common conditions -- congestive heart failure, heart attack, or pneumonia -- are 13% more likely than whites to be readmitted within a month, researchers reported.

But the analysis of Medicare discharge data for more than three million patients, also found disparities related to where patients get care -- both blacks and whites treated at hospitals with a large proportion of black patients had even higher readmission rates, according to Karen Joynt, MD, PhD, of Brigham and Women's Hospital in Boston, and colleagues.

Overall, about one in five older patients admitted to the hospital with heart failure, MI, or pneumonia were readmitted within 30 days, Joynt and co-authors wrote in the Feb. 16 issue of the Journal of the American Medical Association.

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Private Room Intensive Care Units Associated with Lower Infection Rates

ScienceDaily (2011-01-13) -- Converting hospital intensive care units to private rooms is associated with a reduction in the rate at which patients acquire infections, according to a new study.

Partnership Takes Aim At Preventable Hospital Readmissions Among High-Risk Seniors

SCAN Health Plan and Lakewood IPA have partnered with Dovetail Health in a program designed to reduce readmission rates for high-risk seniors following discharge from hospitals and skilled nursing facilities.

Under the new program, high-risk SCAN Health Plan members in Southern California whose primary care physicians are part of Lakewood IPA are now being referred into Lakewood's "Healthy Transitions" program upon discharge. Led by Dovetail, the Healthy Transitions program combines elements of existing transition management programs - such as improved discharge planning and telephonic case management - with a unique focus on medication optimization and adherence.

"We believe that this program will lessen the number of seniors readmitted to a hospital for reasons that are totally avoidable," said Timothy Schwab, MD, chief medical officer for the not-for-profit SCAN Health Plan. "By focusing on those problems most commonly found and tailoring the program to each individual, we can make a significant, positive impact in the lives of many of our members."

In general, patients enrolled in the program take an average of 12 medications and have chronic conditions such as diabetes, chronic obstructive pulmonary disease, congestive heart failure and renal disease. More than 75 percent are at increased risk of falls. One in five seniors nationwide is readmitted within 30 days of discharge at a staggering cost of over $17 billion, and medication-related issues are frequently a factor.

The Healthy Transitions program sends pharmacists to meet patients in their homes following discharge from hospitals and skilled nursing facilities. Healthy Transitions pharmacists review every prescription and over-the-counter medication. During the visits they clarify orders, educate patients and caregivers, identify opportunities to optimize medication schedules, and address issues such as non-adherence. Easy-to-read reports are printed for patients, and a version is prepared for their physicians with key questions or issues highlighted.

In addition to medication counseling and support, the Healthy Transitions program follows patients for 30 days to provide ongoing guidance around chronic illnesses, safety, advance-care planning and other potential readmission risk factors. At the end of 30 days, patients are referred back into the appropriate care-management programs at SCAN or Lakewood IPA.

"Our patients have been very open to having the home visit. The comprehensive counseling, support and assessment from the pharmacist are an asset to the physician and the case managers in the continued coordination of care for these high-risk members," said Robin Tufono, director of outreach programs at Coast.

Full Article

Fewer African Americans Plan for End-of-Life Care - AARP Bulletin

Image by Mike Licht, NotionsCapital.com via Flickr
by: Cynthia Ramnarace | from: AARP Bulletin

Older African Americans are less likely to have a plan for their end-of-life care than their white counterparts, a discrepancy that leaves blacks with less control over their final health care choices.

In the first national analysis of racial discrepancies in end-of-life planning, the National Center for Health Statistics reported Jan. 6 that African Americans in home health care and nursing homes were half as likely as whites to have an advance directive such as a living will or a do-not-resuscitate (DNR) order.

Experts say this disparity means African Americans are more likely to endure unwanted medical procedures and experience unnecessary pain and family strife.

Full Article

Seven Hospitals in Six States to Pay U.S. More Than $6.3 Million to Resolve False Claims Act Allegations Related to Kyphoplasty

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Seven hospitals located in Florida, Mississippi, Texas, South Carolina, North Carolina and Alabama have agreed to pay the United States a total of more than $6.3 million to settle allegations that the health care facilities submitted false claims to Medicare, the Justice Department announced today.

The settlements resolve allegations that these hospitals overcharged Medicare between 2000 and 2008 when performing kyphoplasty, a minimally-invasive procedure used to treat certain spinal fractures that often are due to osteoporosis. In many cases, the procedure can be performed safely as a less costly out-patient procedure, but the government contends that the hospitals performed the procedure on an in-patient basis in order to increase their Medicare billings.

"Hospitals that participate in the Medicare program must bill for their services accurately and honestly," said Tony West, Assistant Attorney General for the Department’s Civil Division. "The Department of Justice is committed to ensuring that Medicare funds are expended appropriately."

Full Department of Justice Press Release

U.S. GAO - Long-Term Care Hospitals: Differences in Their Oversight Compared to Other Types of Hospitals and Nursing Homes

Full Report (PDF, 51 pages) Accessible Text

Summary

This report formally transmits the briefing highlighting differences in the oversight of long-term care hospitals (LTCH), other types of hospitals, and nursing homes. This report is a partial response to a congressional request letter and was used to brief congressional staff on November 29, 2010. We provided a draft of this report to the Department of Health and Human Services (HHS) and to The Joint Commission (TJC)--an accrediting organization that oversees the majority of LTCHs.

Payment Reform and the Mission of Academic Medical Centers | Health Policy and Reform

by Paul F. Griner, M.D.

U.S. academic medical centers (AMCs) are facing new challenges to their financial well-being. As payers seek to control health care costs, teaching hospitals and their medical staffs can anticipate continued payment reductions. Under the fee-for-service system, hospitals respond to payment cuts by increasing their volumes of admissions and ambulatory services while improving efficiency. Although costs per case may decline, overall costs do not. The inevitable result is a further reduction in per-case payments, and the cycle continues — with many undesirable consequences. Costs are inflated, and the quality and safety of care are eroded as the result of unnecessary or inappropriate tests and procedures.

Rather than perpetuating this cycle, AMCs stand to gain by exploring payment reforms that promote evidence-based, rather than income-driven, care. Several such reforms are being proposed or tested, including payment per episode of illness, various forms of capitation, and an annual payment for the care of a defined population. Any of these approaches may include extra payments for meeting or exceeding quality standards. Commonly referred to as bundled payment, these approaches reflect the principle that health care providers should be reimbursed on the basis of the outcomes of care, not the inputs used to achieve them. Bundled-payment programs thus prioritize the discriminating use of health care resources, and the evidence shows that they can achieve cost savings while preserving hospitals’ revenues and physicians’ incomes. Despite concern that bundled payment may cause underutilization of services, experiments have shown that it does not have this effect. Some experts therefore predict that health care organizations will increasingly embrace bundled payments.
Full Article

Workshop Regarding Accountable Care Organizations, and Implications Regarding Antitrust, Physician Self- Referral, Anti-Kickback, and Civil Monetary Penalty (CMP) Laws

This notice announces a public workshop hosted by the Federal Trade Commission (FTC), the Centers for Medicare & Medicaid Services (CMS), and the Office of the Inspector General (OIG) of the Department of Health and Human Services (DHHS).

This workshop will include panel discussions and a listening session on certain legal issues related to Accountable Care Organizations (ACOs). Physicians, physician associations, hospitals, health systems, consumers, and all others interested in ACOs are invited to participate, in person or by calling into the teleconference.

The meeting is open to the public, but attendance is limited to space and teleconference lines available. An agenda will be posted on the CMS Web site at http://www.cms.gov/center/ physician.asp prior to the session.

DATES: Meeting Date: The public workshop will be held on Tuesday, October 5, 2010 from 9 a.m. until 4:30 p.m. Eastern Daylight Time (E.D.T.).


Full Announcement

QuickStats: Hospitalization Rates for Patients Aged ≥65 Years with Septicemia or Sepsis,* by Age Group --- National Hospital Discharge Survey, United States, 2000--2007

September 3, 2010 / 59(34);1108

*Septicemia or sepsis hospitalizations are those with a diagnosis code of 038, 995.91, or 995.92, based on the International Classification of Diseases, Ninth Revision, Clinical Modification, in any of seven diagnoses fields of the National Hospital Discharge Survey.

† Inpatient hospitalization rates for 2000--2007 were calculated using U.S. Census Bureau 2000--based postcensal civilian population estimates. Persons might have multiple inpatient septicemia or sepsis hospitalizations, all of which are reflected in the estimates.

Septicemia and sepsis are bloodstream infections. From 2000 to 2007, the rate of hospitalization for septicemia or sepsis for persons aged 65--74 years increased 57%, from 6.5 per 1,000 to 10.2, and the rate for persons aged 75--84 years increased 52%, from 11.7 per 1,000 to 17.8. During 2000--2007, persons aged ≥85 years had higher rates of hospitalization for septicemia or sepsis than persons aged 65--84 years. From 2000 to 2007, rates for persons aged ≥85 years increased 18%, from 24.7 per 1,000 to 29.2.

SOURCE: National Hospital Discharge Survey, annual files, 2000--2007. Available at http://www.cdc.gov/nchs/nhds.htm.

Full Article

Medical News: Clinical, Economic Costs of Dysphagia Are High - in Critical Care, General Critical Care from MedPage Today

By Nancy Walsh, Staff Writer, MedPage Today

Dysphagia among hospitalized patients -- particularly the elderly -- not only lengthens hospital stays and increases the risk of dying, but also carries significant economic burdens.
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Gay Man Prevented From Dying Partner Wins Settlement | News | Advocate.com

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An elderly gay man who was prevented from seeing his dying partner in the hospital social workers will receive $600,000 in a settlement, reports the Mercury News. Clay Greene, 78, of Guerneville, Calif filed a lawsuit against Sonoma County’s Public Guardian program earlier this year, claiming he was discriminated against because of his sexual orientation.
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Princeton Hospital Test New Room for Patient Care - WSJ.com

By SUZANNE SATALINE

The room's soft white lighting illuminates a wall of etched glass and blond wood. There's hand-laid tile in the shower and the couch unfolds, letting family members stay. Even the shape of this hospital room is quirky, with walls that hide wires and tubing and slant so the occupant will better see the leafy treetops through large windows.

It's peaceful, perhaps practical, and it could be the hospital patient room of the future.

The staff at the University Medical Center at Princeton will soon assign one patient at a time to this newly built room, designed partly with staff input, housed on a post-surgical floor. Designed using research funded with a $2.8 million grant from the Robert Wood Johnson Foundation, the room has ushered Princeton into the growing field of health-care design.

Architects and health-care centers are seeking to prove that a room's layout and accessories can help patients heal faster and cut down on mishaps and staff error, as some research has shown.

"Once we put patients in here, we'll see if everything is right," says Susan G. Lorenz, Princeton's chief nursing officer, who helped design the room.

More hospitals have started to rethink how patient rooms can improve the occupant's health. They're seeking to reduce the spread of infections, the rise in patient falls, and the healing benefits of outdoor views. Patient falls are common in hospitals, and 10% of fatal falls by older adults happen there, according to data compiled by the Institute for Healthcare Improvement. Single rooms are becoming standard, Ms. Lorenz said, because research shows that the privacy reduces infection rates and enhances communication between staff and patients.

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Medical News: Evidence-Based Treatment Improves Older Stroke Victims' Chances - in Cardiovascular, Strokes from MedPage Today

By Kristina Fiore, Staff Writer, MedPage Today

Older stroke patients remain at higher risk for adverse outcomes than younger ones, but the gap has narrowed with wider implementation of evidence-based guidelines, researchers say.

More than 10% of stroke patients over 80 died in the hospital, compared with 3% of those under age 50, Gregg C. Fonarow, MD, of the University of California Los Angeles, and colleagues reported online in Circulation.

But overall use of guideline-recommended therapies improved substantially in older patients from 2003 to 2009, particularly for patients over 90, they said.

During that time, several hospitals and stroke centers have adopted "Get with the Guidelines," an intervention to apply evidence-based guidelines to care. Adopters have seen "substantial improvements ... in performance measures for ischemic stroke patients, including pharmacological and nonpharmacological management in each age group," the researchers wrote.
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Quality of HF Care Not Better Despite Shorter Stays - from MedPage Today

By Todd Neale, Staff Writer, MedPage Today

Although hospital length of stay and inhospital mortality are decreasing for older patients with heart failure, that doesn't necessarily mean quality of care is improving, a large observational study showed.

From 1993 to 2006, length of stay and inhospital mortality significantly decreased in the U.S., but postdischarge mortality and 30-day readmission rates increased -- by a relative 49% and 17%, respectively;Journal of the American Medical Association.
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Absence of Hospital Discharge Planning For Community-Based Services; Is CMS Ignoring an Olmstead Violation?

Steve Gold Information Bulletin #310 (4/10) In the previous Information Bulletin, "Want to Save Medicaid Expenditures," one of the suggestions was:

"Pursuant to the federal Medicaid statutes, acute care hospitals as a 'Condition of Participation' must do 'discharge planning.' HHS/CMS must prohibit federal Medicaid reimbursement to hospitals that, as part of their 'discharge planning,' do not notify a state Medicaid office, well in advance of patient discharge, that a patient will require LTC. Timing is critical so that the State Medicaid officials can meet, discuss, and offer community based services."

Why did we make this suggestion? It was made to ensure that people are not dumped from hospitals and become unnecessarily institutionalized in nursing homes. The critical point of diverting people from nursing homes is at the point of hospital discharge. 60.4% of folks going into nursing facilities come directly from acute care hospitals. The lack of any real discharge planning in hospitals today is a scandal that has gotten little public attention nor from HHS/CMS.

Let's look at what HHS/CMS could have been implementing and requiring since 1994 - 6 years before the Olmstead decision. Discharge planning is one "Condition of Participation" required for hospitals which treat all Medicare and Medicaid patients.

According to federal regulations, 42 CFR part 482, which have the force of law, a hospital must:

(1.) Identify, at an "early stage of hospitalization," persons who are "likely to suffer adverse heath consequences upon discharge if there is no adequate discharge planning."

HHS/CMS - Is unnecessary institutionalization and the violation of Olmstead an adverse consequence?

(2.) Include discharge plans with an "evaluation of the likelihood of a patient needing post-hospital services and of the availability of [post hospital] services."

HHS/CMS - "availability" requires hospital have knowledge of MA Home and Community-based services. Why not, by rule, require hospitals to notify the State Medicaid office at the "early stage" of discharge planning, so patients can be offered a real choice, including community-based services.

(3) Discharge plans must be completed "on a timely basis so that appropriate arrangements for post-hospital care are made before discharge."

HHS/CMS - we assume you agree that "appropriate" includes community-based services? So why aren't you, by rule, telling the hospitals and requiring that they must, during the discharge planning process, offer services in the "most integrated setting".

(4) Discharge plans must be recorded in the patient's record.

Hmmm. That should be easy to check. HHS/CMS - here's a suggestion. Use the MDS information, which CMS collects quarterly, which shows 60.4% of the people in nursing homes were admitted directly from an acute care hospital. Randomly pick a few states and, based on the MDS data, identify from which acute care hospitals the greatest number of nursing home residents come from. Then, go back to those hospitals and review the records of those that were placed in nursing homes. See if these hospital records have any reference to any discharge planning for the individual. If there was discharge planning, were community services offered, or were they just sent to nursing homes. Maybe you could even talk to the nursing home residents and ask them what the hospital did, if anything, other than put them in a nursing home.

HHS/CMS - you have the authority to withhold Medicare and Medicaid prospective funds for hospitals that are dumping folks into nursing facilities, instead of providing a choice of services in the community. You have the authority to revoke provider agreements for violating the Condition of Participation to provide real discharge planning.

HHS/CMS - stop the "hear no evil, see no evil, speak no evil." Find out what's really happening with "discharge planning."

WHAT WE CAN DO:
HHS/CMS needs to hear from all the aging and disability advocates when abuses of discharge planning occurs. Let your regional HHS office know when these abuses occur.

CELEBRATE THE 20TH ANNIVERSARY OF THE ADA
RIGHTS WORTH FIGHTING FOR!

Steve Gold,

The Disability Odyssey continues

ICU Stay Hikes Mortality Risk