Hence, absent offsetting effects from other payment changes, and depending on hospitals' success in controlling overall costs, some portion of any hospital costs will be recovered from Medicare. We proposed to require that the evaluation be included in the medical record. 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. CMS proposes to require that home health agencies develop and implement an effective discharge planning process as a Medicare Condition of Participation (CoP). The Interpretive Guidelines for § 485.635(d)(4) state that the plan includes planning the patient's care while in the CAH as well as planning for transfer to a hospital or a PAC facility or for discharge. This final rule focuses on reforms to discharge procedures that will enhance patient health and safety by filling gaps, while providing appropriate flexibility. Comment: Several commenters requested that we design a process or tool to allow for rapid identification of appropriate PAC organizations, including those that are in the patient's managed care network, to speed up the discharge process. A discharge planning evaluation must include an evaluation of a patient's likely need for appropriate post-hospital services, including, but not limited to, hospice care services, post-CAH extended care services, and home health services; such evaluation must also determine the availability of those services. CAHs are to ensure that adequate patient medical records are maintained and transferred as required when patients are referred. For example, we would not expect that a pediatric patient who is being discharged from the hospital and referred for home health services would be presented a list of HHAs that do not provide services to pediatric patients. Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year of $100 million in 1995 dollars, updated annually for inflation. The commenter recommended that the language be changed to reflect that the information be sent to the receiving facility and made available, upon request, to the health care practitioner. In addition, providing patients with a list of providers that responded within an allotted period of time would not assist the patient in making a decision, as it may unduly limit patient choice based on an arbitrary time deadline. CAHs are to ensure that adequate patient health records are maintained and transferred as required when patients are referred. One commenter stated that we have underestimated the time required of an RN or physical therapist to complete the HHA standards finalized here. The policies and procedures would be approved by the governing body or responsible individual and be specified in writing. We assume 4 hours of legal time at $136 an hour for a cost of $544 and 4 hours of physician time at $203 an hour for a cost of $812. 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. In addition, we do not have the ability to bill the HHA for re-institutionalization of the patient. The commenter Start Printed Page 51869further noted that patients rarely consult with their current agency on the quality of a competitor. Ultimately, these final requirements will ensure that a patient's health care information follows them after discharge from a hospital or PAC provider to their receiving health care facility, whether that be their primary care physician or a SNF. Patient's goals and treatment preferences. One commenter stated that they support the requirement that the discharge planning policies and procedures be developed with input from the CAH's professional health care staff, nursing leadership as well as other relevant departments and be reviewed and approved by the governing body. The new requirements at § 485.642(a) require that the CAH's discharge planning process must identify, at an early stage of hospitalization, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient's representative, or patient's physician. We are issuing this document in accordance with section 1871(a)(3)(B) of the Social Security Act (the Act), which requires notice to be provided in the Federal Register if there are exceptional circumstances that cause us to publish a final rule more than 3 years after the publication date of the proposed rule. Response: We thank the commenters for their feedback regarding a person-centered approach to discharge planning. (1) Any discharge planning evaluation must be made on a timely basis to ensure that appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. Comment: One commenter supported the proposal that requires HHAs to evaluate and revise a patient's discharge plan as needed, and recommended that the timeline for revisions to a discharge plan should be determined by each individual HHA. We note that we encourage providers to include any additional necessary medical information as part of the discharge summary as appropriate and also encourage them to ensure that any specific providers or suppliers or specialty practitioners that are clinically relevant to a particular patient be included in the conveyance of the necessary medical information upon discharge; for instance, when the hospital's health IT system is used to populate a discharge summary with relevant information from the patient's record. As previously discussed, both these numbers would have been about $100 million higher if the time needed for HHA discharge functions had been estimated more realistically. We therefore urge hospitals to develop collaborative partnerships with these community based care organizations in their respective areas to improve transitions of care that might support better patient outcomes. Finally, the HHA must document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records. provide legal notice to the public or judicial notice to the courts. One commenter opposed the inclusion of this requirement in the CoPs for hospitals on the basis that hospitals do not control practitioner-patient interaction. Below is a summary of the different suggestions commenters made: Items to include in the discharge summary only if the HHA performed or facilitated (or otherwise could transmit the information without additional activity): ++ Patient's goals and treatment preferences. It was suggested that CMS require the information be sent to the physician responsible for the home health plan of care, in addition to the receiving facility or health care practitioner, which would ensure that the physician who established the home health plan of care has information to continue to be involved in the patient's care at a later time, as necessary. Proposed Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals (CAHs), and Home Health Agencies (HHAs) November 12, 2015; CMS Updates Guidance for Hospital Discharge Planning May 30, 2013; Medicare Discharge Planning: Think … Comment: One commenter stated that HHAs should not be allowed to discharge patients who have an ongoing need unless they are discharging to a Medicaid consumer direction program. Finally, HHAs also obtain periodic changes in payment rates from both public and private payers. We proposed at § 485.642(c)(7) to require that the patient's discharge plan address the patient's goals of care and treatment preferences. One commenter recommended that CMS provide additional information on what constitutes sufficient information regarding certain medical information elements specified in the proposed rule including: Functional status, advance care plans, transportation needs, and risk assessment. Provisions of the Proposed Regulations and Responses to Public Comments, B. Comment: Several commenters recommended that CMS require hospitals to review their discharge planning processes every 2 years. Section 484.105(c) of the recently implemented HHA CoP final rule requires each HHA to have one or more clinical managers with responsibility for, among other things, coordinating patient care, making referrals, assuring that patient needs are continually assessed, and assuring the development, implementation, and updates of the individualized plan of care. However, we believe that it is not appropriate, and is in fact unduly burdensome, to establish a specific timeframe for this review. While some commenters suggested that CMS include even more specificity in the requirements, most expressed concern that CMS was requiring too much information be provided to the patient upon discharge, and that CMS should not mandate what should be included in the discharge instructions. Comment: Several commenters strongly supported the proposed requirements at § 484.58, “Discharge Planning.” Commenters stated that these new requirements put patients and their needs at the center of the discharge process. documents in the last year, 43 Response: We are not requiring that hospitals and CAHs transmit necessary medical information in a specific manner at this time. Hospitals must not develop preferred lists of providers. These alternatives are discussed throughout the preamble. 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). This site displays a prototype of a “Web 2.0” version of the daily This would have added immensely to the complexity and cost of the discharge planning process. The commenter stated that it is cheaper for the government and it gives patients an opportunity to improve on their physical and mental functions and hopefully be reintegrated into the community. The IMPACT Act in no way limits providers' ability to augment the information provided to patients. The DEL furthers CMS' goal of data standardization and interoperability, which is also a goal of the IMPACT Act. and within a reasonable time frame.”. In addition, the terminology used throughout this rule is used in the Act, including the term “discharge planning process” as set forth in section 1861(ee) of the Act. documents in the last year, 34 Until the ACFR grants it official status, the XML One commenter requested that CMS use the term “transition management” instead of discharge planning. Section 1871(a)(3)(A) of the Social Security Act (the Act) requires the Secretary of the Department of Health and Human Services (the Secretary), in consultation with the Director of the Office of Management and Budget (OMB), to establish a regular timeline for the publication of a final rule based on the previous publication of a proposed rule or an interim final rule. Response: This comment pertains to the oversight of managed care organizations rather than to any specific proposed changes to the discharge planning policy proposals set forth in the Discharge Planning proposed rule. Other commenters stated that CMS should develop streamlined alternatives to the proposals, particularly the discharge summary requirements. While we are finalizing a broad requirement for sending necessary medical information, rather than listing data elements, such as those explicitly aligned with the data referenced as part of the Common Clinical Data Set (CCDS) that was finalized in the 2015 Edition final rule (80 FR 62858), eligible hospitals and CAHs in the Promoting Interoperability Program are required under 42 CFR 495.4 to use EHR technology certified to the 2015 Edition Start Printed Page 51860health IT certification criteria beginning in CY 2019 and are therefore required to provide the elements in the CCDS as part of a summary of care record (81 FR 77555). Using data from the Bureau of Labor Statistics (BLS) for May 2017, we have estimates of the national average hourly wages for all professions (these data can be seen at https://www.bls.gov/​oes/​2017/​may/​oes_​nat.htm). Commenters also stated that confirming a patient's managed care network is the responsibility of the patient and to some extent the responsibility of the patient's health plan. Discharge planning is an important component of a successful transition from hospitals and PAC settings. We proposed to establish a new standard, “Discharge planning process,” to require that the HHA's discharge planning process ensure that the discharge goals, preferences, and needs of each patient are identified and result in the development of a discharge plan for each patient. In addition, providers are reminded to take appropriate steps to ensure effective communication with individuals with disabilities, including the provision of auxiliary aids and services, in accordance with section 504 of the Rehabilitation Act, the Americans with Disabilities Act, and section 1557 of the Affordable Care Act (see, http://www.hhs.gov/​civil-rights and http://www.ada.gov for more information on these requirements). Comment: We received one comment related to the proposed language regarding caregiver support. Removing proposed § 485.642(a) and (b), and replacing these standards with revisions and redesignating as § 485.642(a) titled “Discharge planning process.” The final standard at § 485.642(a) incorporates and combines provisions of the current hospital discharge planning requirements (that are statutorily required for hospitals) with revised provisions from the proposed requirements at § 485.642(c). This rule does not deal with those costs. Response: We disagree with the commenters and have added none of the recommended categories. However, they are not required to meet the CoPs specific to psychiatric hospitals set out at §§ 482.60, 482.61, and 482.62. Commenters recommended that the discharge planning requirements include a nutritional component and that specific language regarding food and nutritional services during the discharge planning process be included in the regulations. 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. We proposed at § 482.43, Discharge planning introductory paragraph, to require that a hospital have an effective discharge planning process that focuses on the patients' goals and preferences and on preparing patients' and, as appropriate, their caregivers/support person(s) to be active partners in their post-discharge care, ensuring effective patient transitions from hospital to post-acute care while planning for post-discharge care that is consistent with the patient's goals of care and treatment preferences, and reducing the likelihood of hospital readmissions. In addition, as a best practice, CAHs should confirm patient or the patient's caregiver/support person (or both) understanding of the discharge instructions. However, most commenters disagreed with certain, specific proposed discharge planning requirements. Some of these commenters noted that without these requirements, some discharges from hospitals have been unsafe or inadequate and have led to readmissions or unnecessary emergency department visits shortly after discharge. However, another commenter believed it may not be necessary to forward such information to the health care practitioner. 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. Hospitals and CAHs may choose to include any of the factors that we originally proposed, as well as those described by commenters, in designing their discharge planning process. We appreciate the suggestion that providers utilize a conflict-free advisor. Counts are subject to sampling, reprocessing and revision (up or down) throughout the day. The IMPACT Act requires that assessment instruments be modified to utilize the standardized data required under section 1899B(b)(1)(A) of the Act, no later than October 1, 2018 for SNFs, IRFs, and LTCHs and no later than January 1, 2019 for HHAs. Additionally, the commenter added that independent living centers should develop relationships with HHAs and give these patients services beyond room and board. We believe that extending this requirement to CAHs by regulation places an unnecessary burden on them. Additionally, commenters urged CMS and ONC to consider ways to encourage the adoption and use of these tools by rural and frontier providers to prevent a digital gap. We expect that hospitals would be responsive to the patient regarding his or her needs and provide information to the patient about these organizations as well as form collaborative relationships with these entities as appropriate. However, one commenter asserted that this requirement is redundant, as it is already included in the regular course of care for patients. The authority citation for part 484 continues to read as follows: Authority: We proposed that patients have the right to access their medical records, upon an oral or written request, in the form and format requested by such patients, 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 patient, including current medical records, within a reasonable time frame. The OFR/GPO partnership is committed to presenting accurate and reliable We did not receive any comments on this standard. Proposed § 482.43(c)(5): We proposed to require that, as part of identifying the patient's discharge needs, the hospital consider the availability of caregivers and community-based care for each patient. In addition, we continue to believe in the importance of person-centered care during the discharge planning process. 804(2)), and Executive Order 13771 on Reducing Regulation and Controlling Regulatory Costs (January 30, 2017). Final Decision: After consideration of the miscellaneous comments, we are not making any additional revisions to § 484.58. Trusted exchange networks allow for broader interoperability beyond one health system or point to point connections among payers, patients, and providers. The hospital must identify in its discharge planning policy the qualified personnel who will be involved in the discharge planning process and must execute their discharge planning process in accordance with their policies. Although we proposed to modify this currently existing requirement to include IRFs and LTCHs, in order to be consistent with the provisions of the IMPACT Act, we expect the discharge planner to facilitate patient choice in any post hospital extended care services as part of the discharge planning process. A number of commenters 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. The Public Inspection page may also These regulations are effective on November 29, 2019. Proposed § 482.43(d)(4): We proposed to require, for patients discharged to home, that the hospital establish a post-discharge follow-up process. the reduction of factors leading to preventable readmissions. We proposed at § 485.642(a) to establish a new standard, “Design,” to require a CAH to have policies and procedures for discharge planning that have been developed with input from the CAH's professional health care staff and nursing leadership, as well as other relevant departments. We believe that this change will assure that receiving facilities and practitioners have access to this information as needed, while not overburdening HHAs to preemptively provide such a potentially large volume of information that may not be helpful to receiving practitioners and facilities. We believe that mandating such additional requirements would be burdensome. The commenter further suggested that certain additional elements be considered, including limitations of the facility's number of RNs, Certified Rehabilitation Registered Nurse (CRRNs), physician availability, amount of therapy, and access to emergency services.Start Printed Page 51861. Pharmacy, DME/oxygen, emergency response system or other vendor contact information (contact persons' names, phone numbers, and fax numbers). to be documented and signed by a licensed and qualified practitioner who is responsible for the patient as long as the practitioner is acting in accordance with all state and local laws, including scope-of-practice laws, as well as with all hospital and medical staff requirements and bylaws, and with any individual privileges granted to the practitioner by the governing body. Response: We understand the commenters' concerns and have revised most of the proposed requirements in this final rule to focus less on prescriptive and burdensome process details, and more on patient outcomes and treatment preferences through the use of enhanced information exchange and innovative practice standards. The HHS threshold used for determining significant economic effect on small entities is 3 percent of costs. The commenters explained that providers should address and document a patient's DME needs during the discharge planning process. Response: Based on the comments that we received, we agree with commenters who stated that this proposal was too process-oriented and too prescriptive. Therefore, in the event of such an emergency, we would expect that patients that are determined for safe discharge to a personal home that may have been adversely impacted should not be directed to shelters without prior consultation with public health and emergency management officials overseeing those shelters. and Medicaid programs. In our view, hospitals already counsel patients on these choices, and the availability of written quality information will not add significantly to the time involved, and may in some cases reduce it (the information, of course, would only be presented as pertinent to the particular decisions facing particular patients). 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