Discharge planning self assessment tool

It's a six-page booklet asking patients and their caregivers to act on more than 15 items in areas including:. The booklet also allocates space for listing medications and upcoming appointments and includes a list of agencies offering community services. Download the CMS booklet by clicking here. Described as a "fact sheet," it covers basic discharge details, such as defining discharge planning and explaining its importance before diving into the caregiver's role in the discharge process, explaining where families and caregivers can receive assistance with care responsibilities, and discussing other critical issues.

A particularly helpful resource comes at the end: a series of basic questions caregivers can ask to help them provide better support following discharge and a checklist detailing the type of care families and caregivers may need to provide.

Download the FCA fact sheet here. Take the Quiz. I want to learn more about. Care Management. Join the Discussion. HHAs express concern about the cost of these cases and about their patient mix. When a beneficiary receives an HHABN stating that services will be terminated, he or she may request that the home health agency submit a demand bill—for further information please see the Medicare Claims Processing Manual Pub.

The home health agency HHA must inform the beneficiary of its decision that Medicare coverage is not available. The HHABN must be signed by the beneficiary or appropriate representative before any services are provided. The HHABN provides the beneficiary with the option to have a demand denial condition code 20 submitted to Medicare for review.

After the last billable service has been provided, demand denials must be submitted promptly. Beneficiaries may pay out of pocket or third party payers may cover the services in question. If the medical review upholds the decision of the HHA that the services were not coverable, the HHA keeps the funds collected from the beneficiary. If the review determines the HHABN notification was not properly executed, or some other factor changed liability for payment of the disputed services to the HHA, the HHA must refund any funds collected.

HHAs must also refund any monies collected if medical review determines that the services were payable by Medicare. The link to access this resource is at the bottom of this page. Under this system, HHAs are paid on the basis of a day episode of care in accordance with standard payment amounts 42 U.

Each patient is assigned to a home health resource group HHRG based on the combination of his or her severity levels on the three OASIS data point elements: clinical severity, functional severity, and services utilization.

The Medicare program requires each participating HHA to provide its Medicare home health patients with:. The Secretary of Health and Human Services is obligated to enforce notice and appeal rights of home health beneficiaries through several means, including intermediate sanctions and terminating the HHA as a Medicare-certified agency 42 U. Under PPS, beneficiaries and their advocates should remain vigilant. Changes in health status or other patient circumstances occurring within a day episode of care should trigger notice to the beneficiary.

CMS responded in its pleadings in Healey v. Shalala that notice and appeal rights are not affected by PPS; that the same notice and appeal processes currently in place apply, including the demand bill process. The requirement is designed to reduce fraud, waste, and abuse by assuring that physicians and other healthcare providers have actually met with potential beneficiaries to ascertain their specific healthcare needs. The specifics of the face-to-face requirement for home health care, and certification after the face-to-face encounter, are included in CMS regulations that were issued on November 17, at 75 Fed.

After an initial delay from January 1, , the face-to-face encountered is required as of April 1, See 42 C. The regulations require that the face-to-face encounter be performed by the certifying physician, by a nurse practitioner, by a clinical nurse specialist who is working in collaboration with the physician, or by a physician assistant under the supervision of the physician. The documentation of the face-to face patient encounter must be a separate and distinct section of, or an addendum to, the certification and must be clearly titled, dated, and signed by the certifying physician.

When the face-to-face encounter is performed by a non-physician, he or she must document the clinical findings of the face-to-face encounter and communicate those findings to the certifying physician.

If the face-to-face encounter occurred within 90 days of the start of care, but was not related to the primary reason that the patient requires home health services or if the patient has not seen the certifying practitioner within 90 days of the start of the episode of home health care, the practitioner must have a face-to-face encounter with the patient within 30 days of the start of the home health care.

Recertification of the need for home health care must be provided at least every 60 days, with a preference for the recertification to occur at the time that the plan of care is revised. The recertification must be signed and dated by the physician who reviewed the plan of care.

According to CMS, recertification does not require face-to-face. Eligibility for Medicare coverage of hospice care is contingent in part upon a hospice physician certifying that the beneficiary has a life expectancy of six months or less if the terminal illness runs its normal course.

Furthermore, the law requires that the hospice physician or nurse practitioner attest that such a visit took place. The new rules were scheduled to become effective on January 1, However, to allow providers the opportunity to establish operational protocols necessary to comply with the face-to-face encounter requirements, full implementation was delayed.

In the meantime, CMS published policy further illuminating how the law has been interpreted and how it will be implemented. As of April 1, , Medicare-certified hospices must fully comply with the face-to-face encounter requirements. A hospice physician or hospice nurse practitioner must have a face-to-face encounter with each hospice patient, whose total stay across all hospices is anticipated to reach the 3rd benefit period, no more than 30 calendar days prior to the 3rd benefit period recertification.

The two most common reasons for referral were for transfer to a community hospital and for arrangements for a care package. The mean number of co-morbidities was three. A total of different types of co-morbidity were recorded on the medical chart on admission, the five most common being hypertension, diabetes, cancer, atrial fibrillation and stroke.

The Cronbach alphas were 0. Doctors recorded a total of 64 different diagnoses on admission and these were regrouped mostly according to a system of 11 categories. Figs show patient scores on the three tools according to admitting medical diagnoses of those included in the study. Table 2 contains patient scores on the three tools according to discharge destinations.

Originally there were 10 recorded discharge destinations; these were regrouped into the six categories shown in the table. Patients discharged from the acute hospital to community hospitals and other facilities for rehabilitation were felt to need about the same level of care and therefore grouped together.

The further care category included those discharged to residential care, nursing home or intermediate care. Those transferred to other hospitals were patients discharged to four psychiatric facilities, two acute care trusts for out-of-area patients, a stroke unit in Poland and an orthopaedic centre.

Patients who went home without a care package had higher scores on all three tools. One outcome of note is that the trust negotiated and purchased a licence for the FIM Uniform Data System for Medical Rehabilitation, as part of the changes taking place in the larger discharge planning project during the time this research was conducted.

Two universal challenges of any tool to measure function are reliability and validity. Thus nurses using tools in practice should enquire about these aspects. One study of 40 patients with traumatic spinal cord injury reported the complete FIM can be used reliably as a self-report postal questionnaire Grey and Kennedy, This research, with Cronbach alpha coefficients of 0.

The significant correlations between both the FIM scores and Alpha FIM scores and the BI scores in this study suggest that the same concept function is what is validly being measured. With a median age of 82 years and a mean of 79, this is the first report of scores on three tools in an older adult population in England.

FIM scores have been reported on younger patients with an average age of 20 range Grey and Kennedy, Another study reported FIM and BI scores in two groups of patients with average ages of 45 range and 52 range van der Putten et al, To our knowledge, this study is the largest sample of FIM scores with the widest range of different medical diagnoses in England. Patients in this study, with a mean total FIM score of 72, had quite a low level of functional independence.

Perhaps the most significant limitation is that the functional assessment scores were measured only once, on approximately day of the acute hospital stay. Future studies should look at changes in patient function over time. In this study, patients were followed only until acute hospital discharge. Thus it is not known if there is a correlation between patient scores on the three tools and final discharge destination.

Nurses searching for a reliable and valid tool to measure function and thus inform discharge planning, could adopt any of these three. Now that there is an agreement for use of the FIM in this trust, further research should measure patient improvement as well as further aspects of reliability and validity.

The FIM, with its greater spread in scores compared with the BI, is perhaps more informative in the greater discharge planning process, especially for additional assessments. Bull, M. Journal of Advanced Nursing ; 4, The information will be stored on a password protected computer that can only be accessed by the research team.

Discharge Resources for Clients. Video Resources. It helps me in talking with clients patients post-stroke. The caregiver really responded to being part of the planning. I was able to stop a discharge today.