For the first time in 25 years, the Centers for Medicare & Medicaid Services (CMS) is modifying the conditions of participation (CoP) for long-term care (LTC) facilities. These changes demonstrate CMS’s increased focus on person-centered care and its recognition of the fundamental role that care transitions play in our healthcare system.
Individualized “Person-Centered” Care Plans
The required completion of an individualized care plan for patients transitioning into a long-term care facility is a core element added to LTC CoP changes. The baseline plan must include services to address patient needs, including those recommended in the patient’s PASRR goals for the patient’s admission and a discharge plan. A reconciliation of the patient’s medications (including pre-admission medications) as well as any follow-up care or services must also be included in the patient’s discharge summary.
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Proposed IMPACT Act Plan
In addition to the two care-transition requirements mentioned above, CMS also proposes an implementation plan for one of the IMPACT Act requirements. The requirement includes assessing patient’s condition for key quality measures, such as pressure ulcers, functional status, cognitive status and special services as the patient is admitted to and discharged from a long-term care facility.
Three Steps to Address the LTC CoP Changes
These changes highlight the need for those facilities and their care teams to create robust, standardized transition processes into and out of the facility, while also helping long-term care facilities provide more person-centered care to patients. Here are some steps to consider as these changes are implemented:
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- Review the processes and technologies used to accept and admit patients into facilities.
- Collaborate with referring care providers and ensure that all the relevant clinical and regulatory information (e.g., PASRR) is accessible as the patient’s needs are assessed to build a care plan.
- Review the processes and technologies used to build out discharge plans and share those with the next set of care providers.
What is your take on the proposed LTC CoP changes? Share your thoughts in the comments section!
