Proposed § 482.43(c)(4): We proposed that the practitioner responsible for the care of the patient be involved in the ongoing process of establishing the patient's goals of care and treatment preferences that inform the discharge plan, just as they are with other aspects of patient care during the hospitalization or outpatient visit. We’ve made big changes to make the eCFR easier to use. Another commenter suggested that there should be a requirement for performance metrics as part of the design of a discharge process so as to inform formative assessment of policies, plans, and procedures, and their success or need for change. documents in the last year, 34 Thus, we believe that hospitals are already following most of these requirements and therefore we will not be assessing any additional burden for this section beyond our estimates of the one-time cost to hospitals to modify their policies and procedures in order to ensure that they are meeting the requirements of this rule. We therefore are not finalizing the requirements at proposed § 482.43(b). documents in the last year. The commenter states that this consistency will facilitate standardization of the information collected and definitions used to improve the process, enhance communication, and ensure everyone is working toward the same goals. However, we would expect that CAHs would not make decisions on PAC services on behalf of patients and their families and caregivers and instead focus on person-centered care to increase patient participation in post-discharge care decision making. Other commenters noted that HHAs do not prescribe controlled substances or other types of medications. Establishing a specific list of information that must be shared from an HHA to another health care provider creates a risk of simultaneously overburdening HHAs with elements that are not applicable and leaving out elements that are critical to assuring a safe and effective care transition in any given situation. Section 3(f) of Executive Order 12866 defines a “significant regulatory action” as an action that is likely to result in a rule: (1) Having an annual effect on the economy of $100 million or more in any 1 year, or adversely and materially affecting a sector of the economy, productivity, competition, jobs, the environment, public health or safety, or state, local or tribal governments or communities (also referred to as “economically significant”); (2) creating a serious inconsistency or otherwise interfering with an action taken or planned by another agency; (3) materially altering the budgetary impacts of entitlement grants, user fees, or loan programs or the rights and obligations of recipients thereof; or (4) raising novel legal or policy issues arising out of legal mandates, the President's priorities, or the principles set forth in the Executive Order. Similar requirements exist for HHAs and CAHs as well. We encourage hospital personnel to be knowledgeable about the services that are provided by their local community based organizations and expect hospital personnel to be able to offer their patients guidance on how to connect with their local community based organizations. In fact, we expect that facilities, which are already electronically capturing patient health care information, are also electronically sharing that information with providers that have the capacity to receive it to the extent such release is permitted under HIPAA. These tools are designed to help you understand the official document Patients in all three settings are the major beneficiaries of this rule. Providers may utilize the appropriate practitioners that they believe will effectively conduct a patient's discharge planning process. Response: We expect hospitals, HHAs, and CAHs to document the patient's refusal in the medical records and continue to make reasonable efforts to work with the patient and/or the patient's caregiver to find appropriate substitutions. The comments regarding the management and oversight of managed care networks and the current payer contracts and those regarding notices of noncoverage do not pertain to any specific proposed changes to the discharge planning policy proposals set forth in the Discharge Planning proposed rule. Therefore, we refer readers to the following links for more information regarding the use of the “teach-back” method during the discharge planning process as well as for additional information on the National CLAS standards: Comment: A few commenters submitted comments regarding documentation. The HHA would not have as part of their medical record consultation results and procedures performed by other facilities. For the other provisions, we considered a wide range of alternatives, but determined that none of them would result in substantial benefits at a reasonable cost. Another commenter recommended adding an additional section for hospitals, HHAs, and CAHs that would require these providers to advise patients of their rights to appeal a discharge or complain about the quality of care and advise the patient of the availability of assistance from Beneficiary and Family Centered Care Organizations. Section 1871(a)(3)(B) of the Act allows the timeline for publishing Medicare final regulations to vary based on the complexity of the regulation, number and … Requirements for Post-Acute Care (PAC) Services (Proposed § 482.43(f)), F. Home Health Agency Discharge Planning (Proposed § 484.58), 1. Mandate that providers collaborate and coordinate with community based organizations on the availability of community supports at discharge. Several commenters submitted comments questioning the proposed requirements regarding the role of the governing body, medical staff, and relevant departments in relationship to developing the discharge planning process, and suggested that the final regulations be much less prescriptive regarding these roles. In addition, to further interoperability in post-acute care, CMS has launched the Data Element Library (DEL), which serves as a publicly available centralized, authoritative resource for standardized data elements and their associated mappings to health IT standards. In the Hospital Innovation proposed rule, we proposed clarifying the requirement for hospitals at § 482.13(d)(2) to state that the patient has the right to access their medical records, including current medical records, upon an oral or written request, in the form and format requested by the individual, if it is readily producible in such form and format (including in an electronic form or format when such medical records are maintained electronically); or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, within a reasonable time frame (81 FR 39475). documents in the last year, 65 The CMS public mailbox can be accessed on our PAC quality initiatives website: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/Submit-a-Question-or-Feedback.html; (4) held a National Stakeholder Special Open Door Forum on February 25, 2015 to seek input on the measures; and (5) sought public input during the February 2015 ad hoc Measure Applications Partnership (MAP) process meeting regarding the measures under consideration with respect to the IMPACT Act domains. Final Decision: After consideration of the comments we received on the proposed rule, we are finalizing the discharge planning requirements with the following modifications: We proposed to re-designate and revise the current requirement at § 482.43(c)(5) (which currently requires that as needed, the patient and family or interested persons be counseled to prepare them for post-hospital care) as § 482.43(d), “Discharge to home,” to require that the discharge plan include, but not be limited to, discharge instructions for patients described in proposed § 482.43(b) in order to better prepare them for managing their health post-discharge. Because of the important role that community based organizations play, we strongly encourage hospitals to develop collaborative partnerships with providers of community-based services. These can be useful Comment: Many comments were submitted regarding the requirement to provide discharge information to the practitioner(s) responsible for follow up care. Comment: One commenter requested clarification regarding the term “clinical record.” The commenter asked if the term “clinical record” is broader than the term “medical record.” The commenter also asked if this would include everything that would also be part of the “medical record,” and recommended that the final regulation substitute the term “individual's medical record” in place of “clinical record” for consistency. One commenter requested that CMS require nursing homes to provide patients with prescriptions before the patient returns home or back to the community. documents in the last year, by the Agricultural Marketing Service The hospital has the flexibility to determine the manner in which it meets the requirement to inform the patient. The commenters stated that requiring CAHs to have a discharge planning CoP would assist in providing a systematic approach to effective and quality patient care. We proposed to establish a new standard, at § 482.43(a), “Design,” and would require that hospital medical staff, nursing leadership, and other pertinent services provide input in the development of the discharge planning process. Medicare and Medicaid programs; revisions to conditions of participation for hospitals--HCFA. CMS established requirements for the Essential Access Community Hospital (EACH) and Rural Primary Care Hospital (RPCH) providers that participated in the seven-state demonstration program in 1993. While HHS is confident that these changes will provide flexibilities to facilities that will minimize cost increases, there are uncertainties about the magnitude of the discussed effects. Some other commenters supported CMS' continued encouragement of the use of PDMPs, but encouraged CMS not to mandate the use of PDMPs. Therefore, while the interpretive guidance will further clarify the CoPs, they will not impose additional requirements beyond those in the CoPs. 12/11/2020, 867 In addition, we refer readers to guidance from Office for Civil Rights on emergency preparedness and ensuring at risk individuals have access to emergency services at the following link: https://www.hhs.gov/civil-rights/for-individuals/special-topics/emergency-preparedness/index.html. for the purpose of ensuring full network-to-network exchange of health information, convene public-private and public-public partnerships to build consensus and develop or support a trusted exchange framework, including a common agreement among health information networks nationally.” A trusted exchange framework can allow for the secure exchange of electronic health information with, and use of electronic health information from other health IT without special effort on the part of the user. Section 2 of the IMPACT Act added section 1899B to the Social Security Act (the Act). For the preceding reasons, we have determined that this rule will not have a significant impact on the operations of a substantial number of small rural hospitals. regulatory information on FederalRegister.gov with the objective of While CAHs are not required to include in the discharge plan a list of HHAs, SNFs, IRFs, or LTCHs, they are required to, like hospitals, assist patients, their families, or their caregivers or support persons in selecting a PAC provider. Trusted exchange networks allow for broader interoperability beyond one health system or point to point connections among payers, patients, and providers. Response: We continue to believe that hospitals and CAHs should assess their discharge planning processes on a regular basis. Section 485.642(b) provides that the CAH must discharge the patient, and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient's follow-up or ancillary care.Start Printed Page 51874. In such cases, any delays in the discharge process will not be attributed to the hospital. We proposed at § 485.642(c)(8) to require that CAHs assist patients, their families, or caregivers in selecting a PAC using IMPACT Act quality measures. Financial interests that are disclosable under Medicare are determined in accordance with the provisions of part 420, subpart C, of this chapter. Other data as required by the IMPACT Act will be publicly available in the near future. Response: We appreciate the commenters' suggestions to allow the HHA to determine, which parts of the plan of care and physician orders are appropriate to include in the discharge summary. 10/30/2018 at 4:15 pm. Many commenters remarked on the proposed discharge planning regulations for hospitals, but indicated that their comments could also be applied to CAHs. Finally, the HHA must document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records. Of course, we encourage providers to use follow-up procedures they find cost-effective for particular categories of patients. Information on upcoming health-related appointments. However, screening is only mandatory for hospital inpatients. Response: We proposed that hospitals be required to make the patient aware that the patient or caregiver needs to verify the participation of HHAs or SNFs in their network. Comment: One commenter recommended that a patient's written notice of beneficiary's rights as an inpatient include a description of the patient's discharge rights. Require that caregivers be notified in advance of the individual's discharge in order to ensure a safe and appropriate discharge back to the community. and Medicaid programs. In addition, we expect that certain information, including a patient's goals and treatment preferences, be included in the patient's discharge or transfer summary and any other relevant documentation. The Public Inspection page may also While we are not establishing a specific timeframe requirement in order to preserve flexibility for hospitals and CAHs, we would recommend that a hospital or CAH to do its periodic review every 2 years at a minimum. Another commenter asked that the final rule acknowledge that it may not be feasible for a hospital to provide complex quality data for each PAC facility that is being considered with the expectation that the hospital explain all of the nuances that account for different ratings. We also received various comments in response to our solicitation for comments related to specific proposals. Revising §§ 482.43 and 485.642, respectively, to now require that the hospital (or CAH) must have an effective discharge planning process that focuses on the patient's goals and preferences and includes the patient and his or her caregivers/support person(s) as active partners in the discharge planning for post-discharge care. In response to the proposed rule, we received 299 public comments. One commenter stated that health plans should be responsible for following up with their enrollees after a hospital discharge. Another commenter suggested that CMS consider adding the role of the “Discharge Intensivist.” The commenter stated that the role can be an assistive role handled through a “Discharge Health Coach (DHC)” to effectuate a discharge plan. better and aid in comparing the online edition to the print edition. Comment: Several commenters requested clarification on whether the proposed requirements would apply to certain provider types or programs that are not mentioned in the proposed rule. 1. Therefore, these comments are out of scope of this rule. Response: We understand that the commenter is concerned about meaningful and successful transitions of care between the hospital and PAC settings. We would expect that the discharge planning process policies and procedures would be developed and reviewed periodically by the hospital's governing body. Some commenters focused on the development of a modular certification program for long-term and PAC providers, who were not eligible for meaningful use incentives under Medicare or Medicaid as authorized by the Health Information Technology for Economic and Clinical Health Act (HITECH Act). Also, the CoPs at § 485.635 require a CAH to develop and keep current a nursing care plan for each patient receiving inpatient services. We believe that each hospital and CAH should have the flexibility to establish its own timeframe for periodic review. 216 3 Discharge Planning in Case Management much more detail regarding how surveyors will interpret whether a hospital has met the CoP and can continue to care for Medicare and Medicaid patients is found in 42 CFR §482.43 Condition of Participation: Discharge Planning … The statutory timing of the IMPACT Act varies for the standardized assessment data described in subsection (b) of the Act, data on quality measures described in subsection (c) of the Act, and data on resource use and other measures described in subsection (d) of section 1899B of the Act. Response: We are sensitive to the concerns expressed by commenters, as we share their goal of streamlining the regulations to balance the need for minimum health and safety requirements with the need for maximum hospital flexibility to achieve patient outcomes. A number of commenter stated that they already routinely screen certain categories of outpatients, such as observation patients, and that automatically requiring discharge plans for patients in these categories would shift resources away from those patients most in need of discharge plan. CAHs could also provide quality data on HHAs based on the patient's preference to continue their care upon discharge to home. The 2015 Edition also defines a core set of data that health care providers have noted is critical to interoperable exchange and can be exchanged across a wide variety of other settings and use cases, known as the Common Clinical Data Set (C-CDS) (80 FR 62608 through 62702). If you are using public inspection listings for legal research, you The hospital must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, the patient's representative, or patient's physician. For all hospitals to comply with this requirement, we estimate a total one-time cost of approximately $17.7 million (4,900 hospitals × $3,604 ($1,680 plus $568 plus $544 plus $812 = $2,780)). The discharge plan must be updated, as needed, to reflect these changes. The commenter states that hospitals frequently present to the patient only the PAC providers that responded favorably within a given timeframe that they will accept the patient, even if only a limited number of providers responded to the request. Many stated that they believe that the current evaluation requirement is effective for screening and targeting high-risk patients who have true discharge needs. Extension of timeline for publication of a final rule. Additionally, other commenters were pleased to see the requirement to ensure that the discharge goals, preferences, and needs of each patient are identified. We also proposed to implement the discharge planning requirements of the For continuity of care and a smooth transition from the HHA, we believe the discharge summary will provide invaluable information to the receiving practitioner/facility to continue to meet the patient's care needs. Conditions of Participation (CoP)—Discharge Planning (Proposed § 482.43), 5. titled, “Medicare and Medicaid Program; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies” (80 FR 68126) that would update the discharge planning requirements for hospitals, CAHs, and HHAs. Response: Section 4321 of the BBA amended the discharge planning requirements to require that the discharge planning evaluation indicate the availability of home health services provided by individuals or entities that participate in the Medicare program. Discharge to Home (Proposed § 485.642(d)(1) through (3)), 5. 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