New CMS rules put the focus on informed patient choice

New discharge planning requirements of the IMPACT Act went into effect Nov. 29 and the rule, finalized by the Centers for Medicare and Medicaid Services on Sep. 30 addresses post-acute care transitions, patient choice and patient access to medical information.

Among other requirements, the rule mandates that hospitals share quality and resource use measures about skilled nursing facilities, home health agencies, inpatient rehabilitation facilities and long-term care hospitals with patients as part of the discharge planning process to fulfill patient goals of care and treatment preferences, and with the desired outcomes of increased transparency, patient empowerment and quality care.

Providers have worked diligently to implement rule-compliant discharge planning processes within a few short weeks, but many are seeking further clarity where the rule remains vague or complex. Here are important considerations:

At a high level, what changes under the Final Rule?
The Final Rule expands upon existing requirements, ensuring that the focus of the discharge planning process is a patient’s goals and treatment preferences, with the ultimate aims of transparency, patient empowerment and quality care. The scope is broadened under new discharge planning requirements to now require sharing data on inpatient rehabilitation facilities and long-term care hospitals; prior to the passing of the rule, hospitals were only required to share data regarding home health agencies and skilled nursing facilities.

The biggest change to the Conditions of Participation for discharge planning is the requirement that hospitals must now incorporate quality and resource use measures into the discharge planning process, and that choice has to be documented in the patient’s medical record. Where patient choice has always been a requirement, the final rule goes a step further and mandates that documentation within the EHR shows informed patient choice – via quality measures and resource use measures – is provided.

What are quality measures and resource use measures, and how do we provide them to patients?
New discharge planning requirements of the IMPACT Act aim to develop cross-setting quality comparisons, through which hospitals must share quality and resource use measures. In theory, by sharing quality data, patients and their families are empowered to become active participants in their transition to a post-acute care facility or other setting.

Quality measures are defined by ElevatingHOME as measures relating to at least one the following domains: standardized patient assessments including functional status, skin integrity, the incidence of major falls, cognitive function and medication reconciliation.

Resource use measures are defined as the total estimated Medicare spending per individual, discharge to community and all-condition risk-adjusted potentially preventable hospital readmission rates.

Providers are required to share with patients and families the quality and resource use measures that may be pertinent to patient decision-making – such that they help fulfill patient goals of care and treatment preferences. Hospitals are not required to share all quality measures for every post-acute provider. In fact, providing a subset of the most relevant measures with the patient may help avoid overwhelming the patient with extraneous information. Although some quality and resource use measures are publicly available, making that information available to patients and families is cumbersome, and CMS expects providers to make reasonable efforts to use the quality and resource use measure data currently available until all measures are finalized and publicly reported.

As a provider, how do we document that we shared quality data with patients in the EHR?
A core component of the final rule mandates that providers must document in the patient’s medical record that post-acute data on quality and resource use measures were shared with the patient during the discharge planning process. Despite this new requirement regarding where patient choice should be documented, there is limited information regarding to what extent providers must make documentation within the medical record. As a result, many case managers remain unsure of the specifics regarding documentation: Do they have to document the list that was shared with the patient? Do they need to record the patient’s final choice?

In the absence of more clearly defined data protocols from CMS, providers’ documentation approach will continue to vary greatly, but there are technology resources that allow for documentation options.

My hospital collects its own quality data on post-acute care providers. Can we use that?

Providers are permitted to use additional available information as they assist patients in the post-acute selection process. The Final Rule does not limit providers’ source of information provided to patients so long as the materials presented align with the patient’s goals of care and treatment preferences and any financial relationship with providers is shared clearly.

In the Final Rule, CMS states that its data is not available in ‘‘real-time,’’ but that up-to-date data is posted as quickly as possible and providers should use these data sources to assist patients as they choose a post-acute provider. However, there are tools that providers can adopt to glean insights that extend beyond what CMS is able to provide for more advanced, real-time data regarding post-acute provider quality and outcomes based on a patient’s specific needs.

Also, though under no strict obligation to do so, CMS encourages providers to be generally aware of a patient’s insurance status and eligibility for post-acute care or Medicaid coverage. Technologies providing a customized search of available post-acute facilities based on insurance, amenities, location, clinical services – and of course, quality and resource use measures – help achieve patient goals of care and treatment preferences.

Conclusion
With the final rule, CMS has signaled to hospitals that they must provide patients with informed choice – not just any choice – of post-acute providers. To do so successfully, provider organizations must implement care coordination technologies that help fulfill the discharge planning requirements of the IMPACT Act by providing real-time, post-acute data, including quality and resource use measures, on Medicare-certified post-acute providers nationwide. Using this data, patients, families and care managers are empowered to make informed decisions about their care and select the post-acute provider that best fits their needs and preferences.

Photo: mathisworks, Getty Images

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