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Reducing Post-Discharge Hospital Readmissions: Set Up the Resident for Success

Like in-house hospital readmissions, post-discharge hospital readmissions can affect provider performance in the Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP), says Carol Hill, MSN, RN, LNHA, RAC-MT, RAC-MTA, DNS-MT, QCP-MT, CPC, president of Hill Educational Services in Warrior, AL. “With the Skilled Nursing Facility 30 Day All-Cause Readmission Measure (SNFRM), for example, if the resident is in your facility for 20 days following their prior proximal acute-care hospitalization and then is discharged home, you will still be measured in those next 10 post-discharge days on whether the resident is readmitted to the hospital.”

In addition to the SNFRM, fiscal year (FY) 2024 (Oct. 1, 2023 – Sept. 30, 2024) performance year data is currently being collected for two other SNF VBP measures that incorporate hospital readmissions during post-discharge time periods: the SNF Healthcare-Associated Infections Requiring Hospitalization (SNF HAI) measure and the Discharge to Community—Post-Acute Care Measure for SNFs (DTC PAC SNF) measure. Note: To learn more about each measure’s readmission window, review the Skilled Nursing Facility Quality Reporting Program Claims-Based Measures Specifications Manual, the 2023 Measure Updates and Specifications Report SNF VBP Skilled Nursing Facility 30-Day All-Cause Readmission Measure – Version 2.0, and the SNF VBP Measures page.

While SNFs have limited control over what happens to a resident post-discharge, a strong discharge planning process can lay the groundwork to give the resident the best chance of a successful transition. Steps that the director of nursing services (DNS) may want to consider implementing include the following:

Match the discharge process to F-tags 660 and 661

“Your discharge planning process should align with F660 (Discharge Planning Process) and F661 (Discharge Summary) in Appendix PP of the State Operations Manual,” says Linda Winston, RN, MSN, BS, QCP-MT, DNS-MT, RAC-CT, a nurse consultant based in Norwich, NY, and director of education at MDS Consultants, LLC.

“The discharge plan is part of the comprehensive care plan,” notes Winston. “While the MDS is the foundational assessment for the comprehensive care plan, any other assessment tools that you use must accurately reflect the resident’s current status, what their goals for discharge are, and what steps need to be taken for the resident to reach those goals and have a successful discharge based on the requirements in F660 and F661. The interdisciplinary team should be using those tools throughout the resident’s stay to evaluate their progress and adjust their care plan or discharge plan as needed.”

Start preadmission

Under F660, the Centers for Medicare & Medicaid Services (CMS) indicates that discharge planning begins at admission, acknowledges Winston. “However, discharge planning really should start preadmission. You want to know what you are looking at before you bring the resident in. On admission, you must validate what you thought. Then throughout the stay, you have that ongoing evaluation to ensure that you are on the right path and that you have a clear timeline of when you bring in people who will support that resident out in the community. If you don’t get a good picture of the resident’s clinical needs preadmission, that slows down your entire care planning and discharge planning process—and increases the likelihood of a hospital readmission if you don’t have the immediate resources needed by the resident.”

Especially since the COVID-19 pandemic, many preadmission contacts between the hospital discharge planner and the admission staff at the SNF are by telephone and fax, notes Winston. “Information can be missed when admission staff don’t do in-person visits at the hospital. If you are experiencing frequent disconnects between what you think the resident will need and what the resident actually needs upon admission, you have to follow up with the hospital discharge planner and provide clear examples of missing information. This will help you collaborate with the hospital discharge planner to get the required information preadmission so that you can be as successful as possible providing care to each resident, including developing a strong discharge plan.”

Appoint a discharge planning team lead

The team should have a clear leader, suggests Winston. “From discharge medications to follow-up appointments to medical equipment, there is a lot that has to be coordinated so that everyone is on the same page. You need to have a staff member leading the discharge planning process who is given the time—and encouraged to take the time—to work closely with the resident, their representative, and/or their primary caregiver, as well as to foster integration within the interdisciplinary team.”

The team lead could be a nurse or another interdisciplinary team member, such as social services, points out Winston. “But, someone has to take ownership to ensure that the resident’s post-discharge care is set up, the right people have received the needed training and education, and they know exactly who to call if they are having trouble at home.”

Incorporate discharge planning into staff meetings

Meetings (e.g., care plan meetings and Medicare Part A meetings) are embedded into the nursing home culture, points out Winston. “Providers have a lot of meetings. The question is: Where does discharge planning fall into place? You need to set aside a block of time at one of these meetings to have an interdisciplinary discussion on discharge planning, regardless of payer source.”

The right team members must be at the table for these meetings, says Winston. “In addition to the team leader and the relevant members of the interdisciplinary team, the team must include the resident and the resident representative. You won’t get a clear picture of what the post-discharge needs are without involving them at the appropriate times along the way.”

If there is a primary caregiver, whether that person is a family member or a paid professional, they will play a significant role in the resident’s post-discharge success, adds Winston. “So, they also must be part of the discharge planning process and be included in the discussion of exactly what the resident’s needs are.”

Start teaching from admission

Staffing shortages have made teaching something of a lost art, notes Hill. “Teaching either the resident or their family members is not always standard practice. However, discharge planning is a complex process with a lot of moving parts, so teaching needs to begin on day one when a resident expects to be discharged home.”

Teaching isn’t the sole responsibility of therapy, adds Hill. “Nursing may need to teach the resident or the family how to administer medications or treatments—and educate them on what is normal vs. a potential concern. For example, if a resident has dark urine because of a new medication and the family member who has taken on the responsibility of changing their catheter bag hasn’t been educated on what to expect, that could result in a trip to the emergency department (ED) and a potential readmission.”

Nursing also may need to provide education to bridge the gap before home health arrives, says Hill. “For example, the home health agency sometimes will not come see the resident on the same day that they are discharged from the SNF. So, if you are sending a resident home with new medicines or treatments, and they will not be getting any community guidance from home health for one to two days, have you educated the resident and the family on what they need to know or do until home health arrives?”

Sometimes, the initial home health nursing visit occurs several days before therapy begins. Delays in initiating home health therapy have the potential to create setbacks in the resident’s functional status (and should be considered in discharge planning), according to “Complex Transitions From Skilled Nursing Facility to Home: Patient and Caregiver Perspectives” in the May 2021 Journal of General Internal Medicine.

In addition, this study found that extensive paperwork can easily overwhelm residents and families, making it difficult to find relevant information when they need it. The teach-back and show-me methods of education can help circumvent information overload. Note: The following resources explain how to use these methods to educate residents and family members:

Work with the NAC to mine the MDS

The MDS also can be a useful source of information for discharge planning, says Hill. “The Oct. 1, 2023, revisions to the MDS item sets put an increased focus on assessment information to help residents successfully transition. Whoever is leading the discharge planning process should be collaborating with the nurse assessment coordinator (NAC) to ensure that the discharge plan reflects and aligns with MDS assessment information that is being collected up to the day of discharge.”

The following AAPACN chart details some of the key MDS items and sections that can assist with discharge planning:

  • A1005 (Ethnicity)

  • A1010 (Race)

  • A1110 (Language)

  • A1250 (Transportation)

  • A2105 (Discharge Status)

  • A2121 (Provision of Current Reconciled Medication List to Subsequent Provider at Discharge)

  • A2123 (Provision of Current Reconciled Medication List to Resident at Discharge)

  • A2124 (Route of Current Reconciled Medication List Transmission to Resident)

  • B0200 (Hearing)

  • B0600 (Speech Clarity)

  • B0700 (Makes Self Understood)

  • B1000 (Vision)

  • B1300 (Health Literacy)

  • C0200 – C0500 (The Brief Interview for Mental Status (BIMS))

  • D0150 (Resident Mood Interview (PHQ-2 to 9))

  • Section GG (Functional Abilities and Goals), including:

    • GG0130: Self-Care (3-day assessment period) Discharge

    • GG0170: Mobility (3-day assessment period) Discharge

  • Section I (Active Diagnoses)

  • Section J (Health Conditions), including:

    • J0300 – J0600 (Pain Assessment Interview)

  • K0520 (Nutritional Approaches):

    • Column 4 (At Discharge)

  • Section M (Skin Conditions)

  • Section N (Medications)

  • O0110 (Special Treatments, Procedures, and Programs):

    • Column c (At Discharge)

  • O0250 (Influenza Vaccine)

  • O0300 (Pneumonia Vaccine)

  • Section Q (Participation in Assessment and Goal Setting)

Note: For additional insights, refer to the Aug. 17, 2021, AAPACN article “Use MDS Section B to Improve Holistic Discharge Planning”; the Nov. 14, 2022, AAPACN article “Discharge Planning: NACs Have a Key Role as an Information Broker,” and Sept. 15, 2020, AAPACN article “Don’t Delay Using Health Literacy in Your Care Planning and Discharge Planning Process.”

Do follow-up phone calls

Prior to COVID-19, some SNFs had begun doing follow-up phone calls to check up on discharged residents, says Hill. “The pandemic put a stop to most calls. However, there are now multiple measures in the SNF VBP, as well as quality measures (QMs) in the Skilled Nursing Facility Quality Reporting Program (SNF QRP) and the Nursing Home Quality Initiative (NHQI), that can benefit from follow-up phone calls within two to three days of discharge. Even though the measures don’t all use exactly the same criteria, they all build off of variations of the same information.”

So, it’s worth taking the time to double-check that what was supposed to happen when the resident discharged is actually happening in those critical first few days at home, explains Hill. “You may be able to take steps that will help keep that individual resident from being readmitted to the hospital, as well as learn vital information that can be used to guide performance improvement.”

The staff member who calls should have a script or checklist of questions to ask, suggests Hill. “You won’t get the information you need if you just ask the resident, ‘How are you doing?’ You have to ask the right questions based on the resident’s discharge plan. For example, questions may include, ‘Did you get your medicines? Was the bed that was ordered for you delivered? Has home health come to see you? Were you able to go to your scheduled doctor’s appointment after you got home?’”

Note: In August 2023, the Quality Improvement Organization (QIO) program issued an updated Improving Nursing Home Discharges Back to the Community: Toolkit and Implementation Guide. These resources include a sample script for a follow-up phone call. Additional information is available here and here.

Pay attention to comorbidities

Some comorbidities can complicate resident discharges, says Winston. “Frankly, they can complicate the admission, and then the resident struggles through discharge and after discharge as well. So, you should understand what comorbidities impact successful discharges and use your facility assessment to determine which comorbidities are in your resident population. This will help you to ensure that you have qualified, competent staff to care for them during their stay—and to implement a stronger discharge planning process.”

Note: The SNFRM, the SNF HAI measure, and the DTC PAC SNF measure all have their own complex set of risk-adjustment variables, including comorbidities. These are detailed in the SNF QRP Claims-Based Measures Specifications Manual and the 2023 Measure Updates and Specifications Report SNF VBP Skilled Nursing Facility 30-Day All-Cause Readmission Measure – Version 2.0. A simpler option for understanding the most common comorbidities related to hospitalizations is the AHRQ Healthcare Cost and Utilization Project (HCUP) statistical brief, Comorbidities Associated With Adult Inpatient Stays, 2019.

Use a QAPI approach to effect change

CMS expects the Quality Assurance and Performance Improvement (QAPI) program to be a core part of the facility operational structure supporting quality of care and quality of life for residents. However, nursing homes don’t always live up to that expectation—as evidenced by the fact that in FY 2023, F867 (QAPI/QAA Activities) was the 15th most frequent citation nationwide at the immediate jeopardy (IJ) level, according to QCOR data accessed on Jan. 23, 2024.

Hospital readmissions sometimes aren’t prioritized in the QAPI program, says Winston. “However, taking a systematic QAPI approach is essential. For post-discharge readmissions, you should review your discharge planning process. What has been successful, why did it work, and what can you learn from that and potentially build upon? What has been less than optimal, why didn’t it work, and how can you improve that process?”

Note: Find tips in the Nov. 28, 2023 AAPACN article “QAPI: How to Maximize Performance Improvement as well as Quality Assurance.”

Boost partnerships with community resources

Providers should make a point to understand what community resources are available to help residents who won’t have adequate support post-discharge, says Winston. “You want to know who your local contact agency (LCA) is—and keep track of when the state changes LCAs.”

Sometimes, integrating with the LCA and other community resources can be difficult, acknowledges Winston. “However, forming partnerships and bringing people together to talk about what is available may make the difference between a resident who is supported to be at home safely vs. a resident who has an unplanned post-discharge hospital readmission.”

Implement CMS tools to audit discharges

The Discharge Critical Element Pathway (form CMS-20132) and the Content of the Discharge Summary and Post-Discharge Plan of Care sections of the F661 guidance in Appendix PP of the State Operations Manual provide a blueprint for resident discharges, says Winston. “Surveyors use the Discharge Critical Element Pathway to review both resident-initiated, planned discharges and facility-initiated discharges, so it can serve as a final overview checklist of whether the team has completed all of the required components of the discharge planning process.”

Note: Critical element pathways are available in the LTC Survey Pathways subfolder in CMS’s Survey Resources folder.

“Then, the F661 guidance covers all of the details that need to be in the discharge summary and the discharge plan of care,” explains Winston. “The discharge planning team leader should use the discharge summary items as a communication tool to guide interdisciplinary conversations throughout the resident’s stay. For example, have you addressed the resident’s customary routine, cognitive patterns, communication, and vision? Doing that will help you take a holistic look at the resident’s needs and goals so that you can individualize the discharge plan to help them be successful.”

Additional AAPACN Resources  

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