The goal of this continuing education offering is to provide nurses with current information on discharge planning. After reading this article, you will be able to:
1. Define the term discharge planning.
2. Describe role transition from staff nurse to discharge planning/case management nurse.
3. Discuss case management activities and the value of discharge planning/case management to the healthcare organization.
You can earn 1 contact hour of continuing education credit in three ways: 1) For im-mediate results and certificate, go to www.advanceweb.com/nurses. Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 008-0-07), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).
Mrs. Temple had an outpatient arthroscopy performed on her right knee and was discharged home with discharge instructions that included the following:
Call the orthopedic surgeon with any questions.
After 2 days postarthroscopy, the patient called her surgeon and complained of redness and pain in her right calf. She was admitted to the hospital and it was determined she had a thrombus in her right leg.
The orthopedic surgeon placed her on a combination of Lovenox 30 mg (subcutaneous) daily for 3 days and Coumadin 5 mg (PO) daily. After checking her prothrombin time (PT) and clotting time levels for 3 days, the internal medicine physician said she could be discharged.
Mrs. Temple needed to continue both the Lovenox and Coumadin at home. She also was instructed to follow up with the physician when she should have her PT/INR rechecked.
Discharge Planner Intervenes
The patient had already received her Lovenox for the day and had not practiced with self-injection when the discharge planner received the order for discharge to home. First, the discharge planner met with the patient to determine her readiness for discharge and assessed for any other possible needs.
The discharge planner asked which pharmacy the patient used, and called the pharmacy regarding authorization for the Lovenox. The patient's pharmacy did not carry Lovenox. However, the pharmacist could tell the discharge planner the patient did not require preauthorization for this medication. (The reason for preauthorization is to determine if there is a cost of the medication for the patient. If preauthorization isn't done prior to obtaining the medication, some insurance plans will not cover the cost and the patient may not be able to afford the medication.)
The discharge planner spoke with the patient and suggested a pharmacy near the hospital that carried the Lovenox dosage she needed. The discharge planner called the pharmacy and provided the order and patient's insurance information. The cost to the patient would be $300, which she could submit to her insurance company for partial reimbursement. (If this cost is prohibitive, the patient might have to stay in the hospital while the clotting time becomes more therapeutic, then switch directly to Coumadin.)
Home Health Services
The discharge planner also obtained an order from the physician for home health services. Although the patient was shown how to perform the injection on an orange and given a video to view on how to perform the procedure, it is not the same as giving yourself an injection. If the patient was sent home without a process for further teaching, the discharge process could fail, causing readmission.
The home health RN would make the initial visit and possibly one follow-up visit to check the patient's technique and answer any questions. The discharge planner worked to make the patient aware the home health agency would want to train either the patient or reliable family/friends to perform the injections.
Discharge planning is defined as determining what the patient's medical needs will be after discharge from a hospital or other inpatient treatment.1
Discharge planning has been an evolving process. In the early 1900s, hospitals were looked at as places to die, so discharge planning was hardly a priority.
Over time, more patients were admitted to hospitals and received care that involved costly advanced technology. As hospital costs increased, insurance companies and third-party payers began to restrict and deny services. It became mandatory for healthcare organizations to develop a discharge planning program that could coordinate care, discharge patients as quickly as possible with positive outcomes and save money.
There are a number of discharge planning models that have been successfully implemented in hospitals. In this discussion of discharge planning, the program discussed is in place at Huntington Hospital (HH) in Pasadena, CA.
Roles & Processes
At HH, each nursing unit has an assigned care coordinator, an experienced RN who manages the care of up to 32 patients. The RN works with a social worker, designated as a discharge planner, who may have a caseload of up to 64 patients. While each team member has distinct roles based on professional training and experience, there is collaboration and overlap in the discharge planning process.
Patients admitted to HH are initially screened by the admissions department about their insurance coverage. This information is then verified by the insurers. Each day, the unit care coordinators receive an insurance status report of their patients. Assistants on the unit follow up with the insurance companies if reviews are needed and keep the coordinators updated. This process is essential for the discharge plan to achieve positive outcomes and for the patient to be discharged according to the treatment plan. However, this does not always happen.
When Planning Fails
Insurance reviews are carried out by telephone or fax. The frequency is dictated by the insurance company and often is based on the patient's severity of illness. An insurance company cannot dictate when a patient is discharged. That is the physician's responsibility as long as there is a justified medical condition. If the patient does not meet the acute admission criteria, it is the care coordinator's responsibility to question this with the physician. If no justification can be noted by the care coordinator and the hospital and insurance MDs disagree, the care coordinator writes an appeal letter to the insurance board. If the insurance company turns down the appeal, the hospital is charged the cost and the patient is billed for uncovered insurance costs.
If the discharge plan fails and a patient needs to be readmitted to the hospital, several things may occur. At HH, an RN will complete an incident report and attempt to identify the reason for the readmission. The financial concerns again link to the payer source. For example, if it is Medicaid (Medi-Cal in California), there is no tracking; if it is Medicare, the patient has a limited number of days and usually wants to use them wisely. If the patient has private insurance, the insurance company may want to assign another insurance case manager to better handle the patient's case in the community.
Staying on Track
In our case study, the discharge planner took several steps to make the discharge a successful one. First, it is necessary to know the payer source, whether it is an insurance company, medical management group, Medicare or Medicaid/Medi-Cal.
The discharge planner talked with the pharmacy about authorization for the medication. Usually it is best and easiest to deal with the patient's current pharmacy, if possible. The preferred pharmacy, in this case, could not provide the needed medication. When this occurs, the discharge planner contacts another pharmacy, which must research the patient's coverage of their medications. At HH, the RN care coordinator takes on this responsibility.
Discharge also includes a home health component, which can be set up through the home health agency itself. The hospital discharge planner or care coordinator knows the home health agencies that contract with HH. The discharge planner presents at least three agencies to the patient/family.
Once the home health agency is chosen, the discharge planner contacts the agency and provides documentation that includes history/physical, physician orders and discharge medications. Before the patient is discharged, the hospital physician orders lab studies and follows the results through the home health agency. HH has a Coumadin clinic, so the physician may refer the patient there.
It is the home health agency's responsibility to contact the insurer to obtain authorization to visit the patient. If there is a problem with authorization, the home care agency consults with the hospital discharge planner for resolution. A satisfied outcome, in this case, is a seamless patient transfer and a satisfied and informed family or other caregiver.
In discharge planning, there are psychological components to the process that, if neglected, can cause the whole plan to fail. For example, it is critical to provide a locus of control for the patient and family when plans are being made. In other words, they need to be assured by the care coordinator/discharge planner that the patient's needs will be met upon discharge home or to a transferring facility. Otherwise, there will be limited acceptance and buy-in.
Meeting with the family frequently helps them know there is a definite timetable in place for discharge. The coordinator/discharge planner knows the length of stay for each patient based on diagnosis/DRGs. However, this arbitrary timeline does not account for comorbidities. Because of the uncertainty of the discharge date, this information is not shared with the family at the admission conference.
Best practices in discharge planning require the process to begin upon admission or, if possible, a pre-plan may be initiated. This may occur during the initial interview, when the nurse asks about the home environment and resources the family and patient have to start a forward/future-oriented thinking process.
The discharge planner then meets with the patient and family, if possible, to discuss the discharge plan, which can consist of return to home or discharge to another facility. This helps the patient and family realize the hospital is not the "end game" and helps them move toward a realistic goal for discharge.
To keep each patient's discharge plan on its timetable, it is essential to have interdisciplinary rounds. At HH, the med/surg-telemetry unit conducts these rounds twice a week. Usually, the dietitian, senior care network personnel (an outpatient management program, especially for Medi-Cal patients) and care coordinator attend.
Second Case Study
The discharge planner received orders to discuss a skilled nursing facility with a patient. The patient insisted she was not going to "that place." The physician thought the patient would qualify for the hospital's inpatient rehabilitation program, but she was not strong enough to participate in the 3 hours of therapy per day required by her insurance to qualify for inpatient rehab.
The patient was from an assisted living facility and recently had a pacemaker inserted. She was using a walker, but physical therapy did not recommend her to return home, since it was Friday and she would have little to no supervision over the weekend. The patient also needed IV antibiotics for 3 more days.
The discharge planner explained to the patient that even though she would prefer to go home, Medicare would not pay for her IV antibiotics at home and she would have limited assistance. The discharge planner also made the patient aware her physician strongly recommended her going to the skilled nursing facility for a short time. The patient finally agreed to the plan. The discharge planner discussed facility options with the patient. The end result was the best option for the patient, even though it required some time for her to process the change and come to terms with it.
Most hospitals combine the role of discharge planner with case management and utilization review. According to the Utilization Review Accreditation Commission, "... what used to be a utilization reviewer is now a healthcare facilitator, or consultant, who has an expanded job description that not only includes healthcare management responsibilities, but may also include cost and benefit negotiations."2
How does the unit nurse transition to the role of the case manager? One way is to take a case management class. It is especially important to learn all the regulations and laws that affect how case management can be utilized in hospitals and other organizations. Classes offered by local community colleges cover the basics of insurance reviews, federal and state regulations regarding discharge planning, and an overview of the case management role.
While formal classes might be a good place to start, nothing can match actual experience. The case manager needs to have several years of experience within different settings in the hospital.
Working on a med/surg floor, for example, for at least 2 years gives a solid basis to nursing theory. Experience in specialty areas such as the ICU and emergency department sharpen assessment skills and the ability to work independently. Working in home health for at least 2 years helps broaden that depth of learning and independent-thinking processes. Physician office experience and outpatient work also assist with gaining knowledge of how health insurance and third-party payers operate. Working as a community case manager allows the learner to develop local resources for patients. The nursing profession offers the most flexibility to move within the scope of nursing to broaden one's skills.
The case manager's main focus within the hospital is to assist the patient along the path of their care. For example, since case managers spend considerable time studying the medical record, they can catch orders that have been missed or should have been ordered and, therefore, can directly affect quality of care.
Third Case Study
A patient was admitted with shortness of breath, chest heaviness and a "feeling of doom." The case manager noted the physician had mentioned ordering a CT angiogram, but none had been ordered. When this omission was caught by the case manager, the RN was notified and the test ordered.
The action of this case manager helps demonstrate impact on quality and fiscal impact. If the CT angiogram was further delayed, it could have changed the patient's outcome, possibly resulting in a higher level of care that could cost the patient both time and money.
The case manager's level of motivation and commitment to lower cost per discharge, reduce length of stay, and discuss alternative treatment options with the physician or the family gains new meaning as the role shifts from working to lower hospital costs to working toward cost-containment on behalf of the community.3
The value of the case manager is that extra pair of eyes looking over the vast written details of a patient's medical life; a colleague who can lend support to the often beleaguered and less-experienced nurses, and act as a resource for both nurses and physicians. Discharge planners practice wholistic care. For example, patients ask them many questions: How can I obtain my glucometer or other durable medical equipment? Who will take care of my pets? This nursing specialty requires the practitioner to have an interest in the whole person not just his medical needs.
1. Group Insurance Concepts. (2007). Insurance glossary: Discharge planning. Retrieved Aug. 28, 2007 from the World Wide Web: http://www.myinsuranceguy.com/glossary.htm#D
2 . McKesson Health Solutions. (2007). Understanding utilization review. Retrieved Dec. 31, 2007 from the World Wide Web: http://www.mckesson.com/en_us/McKesson.com/For+Payors/Private+Sector/Professional+Education/Certified+Professional+Utilization+Review+%2528CPUR%2529.html
3. Daniels, S., & Ramey, M. (2005). The leader's guide to hospital case management. Boston: Jones and Bartlett.
Lynann Layne is a care coordinator/discharge planner at Huntington Hospital, Pasadena, CA.