As hospital advocates criticize low reimbursements to nursing homes and home health, the Centers for Medicare & Medicaid Services (CMS) is bearing down on hospitals to revamp their discharge process when releasing patients to SNFs.
Citing areas of concern related to missing or inaccurate patient information upon discharge, CMS is requiring that hospitals have an effective planning process for this transition in care.
State agencies and accrediting organizations, along with hospitals, are required to have such a process in place, but crucial information still falls through the cracks upon discharge, CMS said in a memo issued on Tuesday.
Notably, serious mental health illnesses, complex behavioral needs and substance abuse disorders may be in documentation, but often information related to underlying diagnoses is missing.
“Additionally, specific treatments that were implemented to help manage these conditions while in the hospital are omitted from patient information upon hospital discharge and transfer to the PAC provider, such as additional supervision that was provided throughout the patient’s hospital stay,” according to the CMS memo.
Mark Howell, director of policy and patient safety for the American Hospital Association (AHA), said in an emailed statement that the association would like to see improvements to CMS discharge planning requirements in order to provide a more “individualized, patient-specific approach.”
Incomplete lists of medications was another concern, the agency said – troubling prescription omissions for psychotropic drugs and narcotics were found by CMS.
Other omissions include, skin tears, pressure ulcers, bruising or lacerations noted upon hospital admission or acquired during hospitalization; medical equipment use; a patient’s preferences and goals for care; and communication about patient home life, and how that might impact their ability to recover.
AHA and its members take the process of discharge planning for their patients “very seriously,” said Howell.
Hospital systems have invested heavily in creating discharge summary reports, he said, and use electronic health record (EHR) systems for health information exchanges, allowing important information to “flow readily” to other professionals along the care continuum.
Still, CMS suggested hospitals review several resources to improve discharge policies and procedures, including a “re-engineered” discharge toolkit, collaborating with SNFs to standardize a process, and conduct case reviews of previous discharges to improve outcomes of future transitions in care.
Another suggestion, which is based on AHA commentary is already happening, included enabling access to patient information via EHRs.
“Our members will continue to emphasize the critical importance of the discharge process and hope that post-acute facilities continue to take steps to make the process more efficient and patient focused,” said Howell.
AHA pushes for higher SNF reimbursements
AHA also submitted a letter this week to CMS on the SNF proposed payment rule, calling for higher reimbursements to SNFs. AHA’s recommendations fall in line with suggestions from the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) to rethink how the payment rule is calculated.
“The AHA would like to stress to CMS the importance of SNFs’ role in the continuum of care, including on hospitals’ ability to properly care for and safely discharge patients in a timely manner,” Stacey Hughes, executive vice president of government relations and public policy, said in a letter to CMS. “As SNFs and other post-acute providers have been strained by the pandemic, the ripple effects have been felt throughout the continuum of care.”
Both parties believe the current calculation of Medicare reimbursement to SNFs isn’t able to adequately adjust for sudden changes within the long-term care community. And Hughes said that while the proposed 2024 reimbursement rates are 3.7 percent above the previous year, that figure is still well below the estimated 18 percent cost increases for hospitals between 2020 and now.
“AHA is appreciative of the net positive update, particularly the positive forecast error adjustment. However, we remain concerned that CMS’ market basket approach continues to show lags in recognizing inflationary trends and may not fully capture the rising costs of care,” said Hughes, executive vice president of government relations and public policy for AHA, referring to the 3.7% increase in Medicare.
Hughes penned the AHA letter to CMS on June 5.
Citing a recent analysis from Kaufman Hall in its National Hospital Flash Report, AHA said overall expenses in acute care have risen 18% since 2020, and that while SNFs have a different mix of goods and services, key components of both market baskets are the same – including a heavy reliance on nurses, therapists and medical supplies.
The same report found SNF contract labor costs have skyrocketed 258% since 2019.
“Despite these double- and triple-digit rising costs, the market basket updates for SNFs have been in the low single digits: 2.2% in FY 2021, 2.0% in FY 2022 and 3.6% in FY 2023,” said Hughes. “Although CMS provides forecast error adjustments to ‘true-up’ differences in the forecasted and actual market baskets, these adjustments come two years later, which could seriously strain providers in the interim.”
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