Discharge Planning: Everything Old is New Again

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By Glenda Motta RN, MPH

In 1978, I was hired to develop a comprehensive discharge planning program at an inner city hospital in Washington, D.C. Way before DRGs and any reimbursement limits were placed on hospitals, this facility knew it had a problem. 40 patients had a length of stay that exceeded 60 days! Can you imagine that scenario today?

The new program was designed to begin care planning with an assessment at admission, focusing on a team comprised of the unit nurse managers, therapists, social workers, physicians, pharmacist, hospice expert, and the patient’s insurer. Many of our patients were medical assistance recipients, so we had to look to the city for resources. Initially, we targeted those on our “long-term stay” list. Then the program was implemented for all new admissions.

Naively, I still think that hospitals are doing a great job with discharge planning. Based on high readmission rates for Medicare beneficiaries due to the lack of comprehensive planning and coordination of post-hospital care, this is obviously not the case.

Findings of the first national study examining how effectively communities and hospitals coordinate care for some of their sickest patients show pervasive problems with patient care after hospital discharge (www.dartmouthatlas.org). The Medicare Payment Advisory Commission (MedPAC) reported that in 2005, 17.6% of hospital admissions resulted in readmission within 30 days of discharge, 11.3% within 15 days, and 6.2% within 7 days. Data are available for hospital referral regions and for more than 1,900 hospitals, as well as counties and states.

Why is this important? Congress and President Obama have identified hospital readmissions as a way to reduce Medicare spending. Provisions in the Patient Protection and Affordable Care Act of 2010 intend to reduce preventable hospital readmissions by reducing Medicare payments to certain hospitals with high preventable readmission rates. Initial efforts will begin in October 2012 and focus on patients with heart failure, acute myocardial infarction, and pneumonia.

This new provision has the potential to hurt certain hospitals by hundreds of thousands of dollars. So, what is the solution? Experts have identified a number of approaches that hospitals should take, including:

  • Better quality care during hospitalizations — effective use of diagnosis-specific clinical decision support tools.
  • Improved communication among providers, and with patients and caregivers — particularly between the inpatient and outpatient providers of care.
  • Care planning that begins with an assessment at admission.
  • Clear discharge instructions, with particular attention to medication management.
  • Discharge to a proper setting of care.
  • Timely physician follow-up visits — with primary care provider and appropriate specialists; preferably the appointment should be scheduled prior to discharge.
  • Appropriate use of palliative care and end-of-life planning should be built into the hospital discharge process. Palliative specialists and hospice expertise need to be integrated components of post-hospital planning.

It sounds to me like everything old is new again. I wonder…what has everyone been doing since I left that position in 1979?

About The Author
Glenda Motta RN, MPH is a reimbursement consultant and wound care expert, publishing over 125 articles and books, serving as the President of the WOCN (1987-1989), and founding GM Associates, Inc., a healthcare marketing and reimbursement firm.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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