IntroductionPost-acute care is a growing and essential health and social service, accounting for more $2.7 trillion spent on personal health care, and, of that, almost 15% of total Medicare spending. Show
The AHA's nearly 5,000 member hospitals, health systems and other health organizations includes 3,300 post-acute care providers, including free-standing post-acute hospitals and post-acute units. Post-acute care settings include long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs) and home health agencies. AHA supports enhanced coordination between general acute-care hospitals and post-acute providers to improve overall quality of care and reduce total health spending. The AHA meets the unique needs of post-acute care providers through
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Provider/supplier and description of proposed provisions | Number of affected entities | Estimated costs ($ millions) |
---|---|---|
Annual | ||
Hospitals (§ 482.43) | 4,900 | ( * ) |
HHAs: Discharge Planning Process(§ 484.58) | 12,600 | 213.4 |
HHAs: Requests for Information (§ 484.58) | 12,600 | 1.5 |
Total | 214.9 | |
One-time | ||
Hospitals (§ 482.43) | 4,900 | 17.7 |
CAHs (§ 485.642) | 1,353 | 1.9 |
HHAs (§ 484.58) | 12,600 | 10.8 |
Cost of reviewing final rule | 18,853 | 16.1 |
Total | 46.5 | |
* Less than $1 million. |
C. Anticipated Effects
1. Effects on Hospitals (Including LTCHs and IRFs), CAHs, and HHAs
We have accounted for the regulatory impact of these changes through the analysis of costs contained in the ICR sections previously mentioned in this final rule. We believe these estimates encompass most additional burden on hospitals, CAHs, and HHAs, with the exception of the following one-time costs to review the revised requirements and adjust internal procedures to assure compliance, particularly in the area of providing quality information to patients for multiple providers of post-discharge services. Any burden associated with the changes to the CoPs not accounted for in the ICR section or in the RIA section was omitted because we believe it would constitute an usual and customary business practice and would not be subject to the PRA in accordance with 5 CFR 1320.3(b)(2). Nor would it constitute an added cost for purposes of RIA estimates if we added a regulatory requirement that reflected existing practices and workload. We note that we do not estimate costs for the newly added requirement to present quality and cost information to those hospital patients who face a decision on selection of post-discharge providers. 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). Indeed, all providers affected by this rule already have access to quality information from the CMS websites Hospital Compare, Nursing Home Compare and Home Health Compare, as well as other public and private websites and their own knowledge of local providers, and presumably many or most use this information as appropriate to counsel patients.
Hospitals will need to review their current policies and procedures and update them so that they comply with the modified requirements, which will be a one-time burden on each hospital. We estimate that an administrator will spend 8 hours on this activity for a total of 8 hours per hospital at a cost of $1,680 (8 hours × $210 for an administrator's hourly salary cost), together with an RN or equivalent for an additional 8 hours at a cost of $568 (8 hours × $71 for an RN salary cost). Lawyer and physician time will also be used. 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 all hospitals to comply with this requirement, we estimate a total one-time cost of approximately $17.7 million (4,900 hospitals × $3,604 ($1,680 plus $568 plus $544 plus $812 = $2,780)).
We are establishing a new standard at § 484.58(a), “Discharge planning process,” to require that the HHA's discharge planning process provide certain information to those patients who are discharged or transferred to another post-acute care provider in order to assist patients and families in selecting a provider that meets the patient's needs and goals. HHAs will need to review their current policies and procedures and update them so that they comply with the requirements in § 484.58(a), which will be a one-time burden on the HHA. We estimate that this will require an administrator using the average hourly salary of a medical and health services manager as determined by the BLS, doubled to account for fringe benefits and overhead. We estimate that the administrator will spend 8 hours on this activity for a total of 8 hours per HHA at a cost of $856 (8 hours × $107 for an administrator's hourly salary). For all HHAs to comply with this requirement, we estimate a total one-time cost of approximately $10.8 million (12,600 HHAs × $856).
The requirement at § 485.642(a)(8), which is associated with the IMPACT Act, will require CAHs to review their current policies and procedures and update them so that they comply with the new requirements, which will be a one-time burden on the CAH. We estimate that the administrator will spend 8 hours on this activity for a total of 8 hours per CAH at a cost of $856 (8 hours × $107 for an administrator's hourly salary cost), together with an RN or equivalent for an additional 8 hours at a cost of $568 (8 hours × $71 for an RN salary cost). The total burden hours are 21,648 (16 hours × 1,353 CAHs). For all CAHs to comply with this requirement, we estimate a total one-time cost of approximately $1.9 million (1,353 CAHs × ($856 plus $568)).
Our estimates of the effects of this regulation are subject to significant uncertainty. While HHS is confident that these changes will provide flexibilities to facilities that will minimize cost increases, there are uncertainties about the magnitude of the discussed effects. However, we have based our overall assumptions and best estimates on our ongoing experiences with hospitals, HHAs, and CAHs in these matters.Start Printed Page 51880
In addition, as we previously explained, there may be significant additional health benefits, such as the reduction in patient readmissions after discharges and the reduction of other post-discharge patient complications. The Discharge Planning proposed rule was estimated to have total first year costs of $454 million (80 FR 68148), and annual costs thereafter of $396 million. 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. This final rule, in contrast, has estimated total first year costs of $262 million and annual costs thereafter of $215 million. This reduction of costs by more than half reflects some downward re-estimates, but mainly our efforts to remove overly prescriptive and costly process requirements that had originally been proposed. It also reflects the many comments we received pointing out ways to improve the rule. These changes show both the benefits of the public comment process under the Administrative Procedure Act, and the focus of CMS in developing final rules in complying with the goals of the laws and Executive Orders previously discussed, especially Executive Orders 12866, 13563 and 13771.
2. Effects on Small Entities
The Regulatory Flexibility Act (RFA) requires agencies to analyze options for regulatory relief of small entities, if a rule has a significant impact on a substantial number of small entities. For purposes of the RFA, we estimate that the great majority of the providers that will be affected by our rules are small entities as that term is used in the RFA. The great majority of hospitals and most other health care providers and suppliers are small entities, either by being nonprofit organizations or by meeting the SBA definition of a small business. Accordingly, the usual practice of HHS is to treat all providers and suppliers as small entities in analyzing the effects of our rules.
As shown in Table 1, we estimate that the recurring costs of this final rule will cost affected entities approximately $215 million a year. Virtually all of these costs will impact HHAs. Total annual revenues of HHAs are approximately $100 billion a year (see Anne B. Martin et al, “National Health Care Spending In 2017,” Health Affairs, January 2019) and there are about 12,600 HHAs. Hence, the average cost per HHA would be about $17,000, about one fifth of one percent of annual revenues. All HHAs are not “average” in size, and about 2,000 of them have fewer than 10 employees. But our annual cost estimates are directly proportional to number of patients, so costs to even the smallest HHAs would be well under one percent of annual revenues. The HHS threshold used for determining significant economic effect on small entities is 3 percent of costs. Accordingly, after a review of cost effects on HHAs, hospitals, and CAHs, we have determined that this rule will not have a significant economic impact on a substantial number of small entities, and certify that a Final Regulatory Flexibility Analysis is not required. Regardless, this RIA and the remainder of the preamble together meet the RFA requirements for such an analysis. In particular, we call attention to the many places in the non-RIA sections of the preamble where public comments helped us to analyze particular options and reject those that would have unnecessarily placed far higher burdens on HHAs or other entities. Specifically, our rejection of options that would have required consultations with health care professionals of many kinds, rather than consultations only as necessary for a particular patient, avoided very substantial costs on small entities.
Under the proposed rule costs to hospitals would have exceeded $100 million annually. We note that quite apart from the gross amount of such compliance costs being a small fraction of revenues or costs of affected entities, net costs will be far smaller. Payment for hospital inpatient services for Medicare beneficiaries is paid primarily according to Medicare severity diagnosis-related groups (MS-DRGs), and MS-DRGs for hospital procedures are periodically revised to reflect the latest estimates of costs from hospitals themselves, as well as from other sources. 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. Moreover, hospitals can and do periodically revise their charges to private insurance carriers (subject in part to negotiations over rates) and for the approximately half of all patients who are “private pay” cost increases can be partially offset in that way. As for CAHs, they are largely paid on a cost basis for their Medicare patients, and will presumably be able to recoup additional costs through periodic adjustments to public and private payment rates. Under this final rule hospital and CAH costs have been essentially eliminated, and hence we anticipate no impact on public and private payment rates. Finally, HHAs also obtain periodic changes in payment rates from both public and private payers. In all three cases, we have no way to predict precise future pathways or exact timing however, we believe that most of the recurring costs will be recovered through payments from third party payers, public and private.
In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if a rule may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 604 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a metropolitan statistical area and has fewer than 100 beds. 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.
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. In 2019, that threshold is approximately $154 million. Although this rule does not technically require HHAs to incur the costs unless they participate in Medicare, as a practical matter few HHAs could remain in business without participating in Medicare and these costs exceed this threshold in early years before subsequent payment increases take increased costs into effect. Mandated spending for CAHs, in contrast, is largely reimbursed on a cost basis and would not count as an unfunded mandate even in early years. This RIA and the other preamble sections together meet the UMRA requirements for analysis of the costs to these providers.
Executive Order 13132 establishes certain requirements that an agency must meet when it issues a proposed rule (and subsequent final rule) that would impose substantial direct requirement costs on state and local governments, preempt state law, or otherwise have federalism implications. This final rule will not have a substantial direct effect on state or local governments, preempt state law, or otherwise have federalism implications.
3. Effects on Patients and Medical Care Costs
Patients in all three settings are the major beneficiaries of this rule. Research cited earlier in this preamble strongly Start Printed Page 51881suggests that there would be reductions in morbidity and mortality from improving services to these patients through improved discharge planning. We are, however, unable to quantify either the volume or dollar value of these expected benefits. We are not aware of reliable empirical data on the benefits of improved discharge planning. In addition, there are multiple initiatives affecting the same patients (for example, the Hospital Readmissions Reduction Program, the Medicare and Medicaid EHR Incentive Program, and the Accountable Care Organizations under the Medicare Shared Savings Program). This makes it challenging to sort out the separable benefits of this rule. Nonetheless, the number of patients potentially benefitting is significant.
There are existing requirements in place for discharge planning and for reducing adverse events such as hospital readmissions, both in regulations governing patient care and in payment regulations, but little or no data exist on the effectiveness of these requirements compared to the normal effects of good medical practice. The changes that will be implemented by this rule are an additional overlay on top of existing practices and requirements. It is challenging to disentangle all these overlapping factors. Therefore, existing data demonstrate that even small improvements can have effects as large as those previously suggested in this rule. For example, one meta-analysis showed that transitional care that promotes the safe and timely transfer of patients from hospital to home has been proven to be highly effective in reducing readmissions.[1]
4. Regulatory Review Cost Estimate
One of the costs of compliance with a final rule is the necessity for affected entities to review the rule in order to understand what it requires and what changes the entity will have to make to come into compliance. The particular staff involved in such a review will vary from provider to provider. We believe that a good approximation for a range of staff would be a person such as a medical and health service manager. Using the wage information from the BLS for medical and health service managers (Code 11-9111), we estimate that the cost of reviewing this rule is $107 per hour, including overhead and fringe benefits https://www.bls.gov/oes/2017/may/oes_nat.htm. Assuming an average reading speed, we estimate that it will take approximately 4 hours for each of the staff involved to review this final rule and its relevant sections and that on average two persons on staff will engage in this review (more for hospitals and CAHs and fewer for HHAs). For each entity that reviews the rule, the estimated cost is therefore $856 (4 hours each × 2 staff × $107 per hour each). Therefore, we estimate that the total cost of reviewing this rule, assuming two reviewers per affected entity, is $16.1 million ($856 × 18,853 affected entities).
D. Alternatives Considered
As we previously stated in this final rule, some of these provisions are mandated under the IMPACT Act; therefore, no major alternatives were considered for those provisions. 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.
For all provisions, we attempted to minimize unnecessarily prescriptive methods or procedures, and to avoid any unnecessarily costly and burdensome requirements. Of particular importance for this final rule, the public comments were exceptionally useful in identifying weak or unjustified provisions in the proposed rule as well as in identifying alternatives. These alternatives are discussed throughout the preamble. The three most costly alternatives that we considered and rejected were requiring specific post-discharge procedures for every patient, requiring that discharge plans be prepared and revised on specific hourly schedules for every patients, and requiring direct individual consultation with a wide range of health care professionals for every patient.
For the alternative of specific post-discharge follow-up procedures, we concluded that the range of procedures was so great (including such very low cost procedures as automatically generated text or email reminders about medication compliance, and such high cost procedures as home visits by nurses), and the range of patient situations so wide (including in many cases no likely benefit from follow-up and in others no efficient way to predict likely benefits), that we could devise no reasonable or practicable requirement that would sensibly apply to all or most patients. Of course, we encourage providers to use follow-up procedures they find cost-effective for particular categories of patients.
The alternative of requiring specific hourly deadlines for beginning a discharge plan would have created immense costs due simply to the myriad circumstances of hospital patients, as described by many examples in the comments. Likewise, commenters identified no consequential benefits, and major costs, were we to impose discharge planning on ambulatory care not even involving an overnight hospital stay, and involving such low risk procedures as providing tooth fillings, cataract surgery, and carpal tunnel surgery.
The third alternative arose from comments from a number of professional associations and individual professionals asking that we mandate use of their particular professions in discharge planning for every patient. These would also have been very costly to impose. As previously discussed, we found no reason to believe that routinely using these professionals in all discharge planning would have provided consequential benefits over and above benefits from selective consultation where indicated by patient-specific conditions.
E. Cost to the Federal Government
When these requirements are finalized, CMS will update the interpretive guidance, update the survey process, and provide training. In order to make these three changes, we anticipate initial, one-time federal startup costs at 4 or 5 person-years, and hence total cost of approximately 1 million dollars including overhead costs and fringe benefits. CMS plans to rely on CMS program management resources to support these costs. The continuing annual costs (survey process-recertifications, enforcement by states or accredited organizations, appeals, AO) will not change from current levels.
F. Accounting Statement
As required by OMB Circular A-4 (available at https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/circulars/A4/a-4.pdf), in Table 2 we present an accounting statement showing the classification of the costs and benefits associated with the provisions of this final rule. The accounting statement is based on estimates provided in this regulatory impact analysis. We have used 10 years as an estimating horizon, and used low and high estimates that are 25 percent lower or higher than our primary estimate. We note that the accounting statement for the proposed rule showed annual costs of about $420 million in 2015 dollars, and that the changes made in this final rule have cut that cost in half. This reduction is even larger in real terms because public comments showed us that the Discharge Start Printed Page 51882proposed rule would have been about $100 million annually more costly than estimated.
Table 2—Accounting Statement: Classification of Estimated Costs and Benefits
[$ in millions]
Category | Primary estimate | Low estimate | High estimate | Units | ||
---|---|---|---|---|---|---|
Year dollars | Discount rate | Period covered | ||||
Benefits—Qualitative not quantitative or monetized | Potential Reductions in morbidity, mortality, and medical costs for hospital, HHA, and CAH patients. | |||||
Costs—Annualized Monetized Costs of Discharge Planning to Medical Care Providers | 220 | 170 | 280 | 2017 | 7% | 2019-2028 |
220 | 170 | 280 | 2017 | 3% | 2019-2028 | |
Transfers | None. |
In accordance with the provisions of Executive Order 12866, this rule was reviewed by the Office of Management and Budget.
G. Regulatory Reform Analysis Under Executive Order 13771
Executive Order 13771, titled Reducing Regulation and Controlling Regulatory Costs, was issued on January 30, 2017 and requires that the costs associated with significant new regulations “shall, to the extent permitted by law, be offset by the elimination of existing costs associated with at least two prior regulations.” This final rule imposes costs and therefore is considered to be a regulatory action under Executive Order 13771. We estimate that this rule will impose annualized costs of approximately $175 million discounted relative to 2016 over a perpetual time horizon.
H. Congressional Review Act
Pursuant to the Congressional Review Act (5 U.S.C. 801 et seq.), the Office of Information and Regulatory Affairs designated this rule as a major rule, as defined by 5 U.S.C. 804(2). As such, this rule has been transmitted to the Congress and the Comptroller General for review.
Start List of Subjects
List of Subjects
42 CFR Part 482
- Grant Programs-health
- Hospitals
- Medicaid
- Medicare
- Reporting and recordkeeping requirements
42 CFR Part 484
- Health facilities
- Health professions
- Medicare
- Reporting and recordkeeping requirements
42 CFR Part 485
- Grant programs-health
- Health facilities
- Medicaid
- Privacy
- Reporting and recordkeeping requirements
End List of Subjects
For the reasons set forth in the preamble, the Centers for Medicare and Medicaid Services amends 42 CFR chapter IV as set forth below:
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PART 482—CONDITIONS OF PARTICIPATION FOR HOSPITALS
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1. The authority citation for part 482 is revised to read as follows:
End Amendment Part
42 U.S.C. 1302, 1395hh, 1395rr, and 1395lll unless otherwise noted.
End Authority Start Amendment Part
2. Section 482.13 is amended by revising paragraph (d)(2) to read as follows:
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Condition of participation: Patient's rights.
* * * * *
(d) * * *
(2) The patient has the right to access their medical records, including current medical records, upon an oral or written request, in the form and format requested by the individual, 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 individual, and within a reasonable time frame. The hospital must not frustrate the legitimate efforts of individuals to gain access to their own medical records and must actively seek to meet these requests as quickly as its record keeping system permits.
* * * * *
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3. Section 482.43 is revised to read as follows:
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Condition of participation: Discharge planning.
The hospital must have an effective discharge planning process that focuses on the patient's goals and treatment preferences and includes the patient and his or her caregivers/support person(s) as active partners in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient's goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to preventable hospital readmissions.
(a) Standard: Discharge planning process. The hospital'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.
(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.
(2) 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-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient's access to those services.Start Printed Page 51883
(3) The discharge planning evaluation must be included in the patient's medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient's representative).
(4) Upon the request of a patient's physician, the hospital must arrange for the development and initial implementation of a discharge plan for the patient.
(5) Any discharge planning evaluation or discharge plan required under this paragraph must be developed by, or under the supervision of, a registered nurse, social worker, or other appropriately qualified personnel.
(6) The hospital's discharge planning process must require regular re-evaluation of the patient's condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(7) The hospital must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were readmitted within 30 days of a previous admission, to ensure that the plans are responsive to patient post-discharge needs.
(8) The hospital must assist patients, their families, or the patient's representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The hospital must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences.
(b) Standard: Discharge of the patient and provision and transmission of the patient's necessary medical information. The hospital must discharge the patient, and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient's follow-up or ancillary care.
(c) Standard: Requirements related to post-acute care services. For those patients discharged home and referred for HHA services, or for those patients transferred to a SNF for post-hospital extended care services, or transferred to an IRF or LTCH for specialized hospital services, the following requirements apply, in addition to those set out at paragraphs (a) and (b) of this section:
(1) The hospital must include in the discharge plan a list of HHAs, SNFs, IRFs, or LTCHs that are available to the patient, that are participating in the Medicare program, and that serve the geographic area (as defined by the HHA) in which the patient resides, or in the case of a SNF, IRF, or LTCH, in the geographic area requested by the patient. HHAs must request to be listed by the hospital as available.
(i) This list must only be presented to patients for whom home health care post-hospital extended care services, SNF, IRF, or LTCH services are indicated and appropriate as determined by the discharge planning evaluation.
(ii) For patients enrolled in managed care organizations, the hospital must make the patient aware of the need to verify with their managed care organization which practitioners, providers or certified suppliers are in the managed care organization's network. If the hospital has information on which practitioners, providers or certified supplies are in the network of the patient's managed care organization, it must share this with the patient or the patient's representative.
(iii) The hospital must document in the patient's medical record that the list was presented to the patient or to the patient's representative.
(2) The hospital, as part of the discharge planning process, must inform the patient or the patient's representative of their freedom to choose among participating Medicare providers and suppliers of post-discharge services and must, when possible, respect the patient's or the patient's representative's goals of care and treatment preferences, as well as other preferences they express. The hospital must not specify or otherwise limit the qualified providers or suppliers that are available to the patient.
(3) The discharge plan must identify any HHA or SNF to which the patient is referred in which the hospital has a disclosable financial interest, as specified by the Secretary, and any HHA or SNF that has a disclosable financial interest in a hospital under Medicare. Financial interests that are disclosable under Medicare are determined in accordance with the provisions of part 420, subpart C, of this chapter.
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PART 484—HOME HEALTH SERVICES
End Part Start Amendment Part
4. The authority citation for part 484 continues to read as follows:
End Amendment Part Start Authority
42 U.S.C. 1302 and 1395(hh) unless otherwise indicated.
End Authority Start Amendment Part
5. Section 484.58 is added to read as follows:
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Condition of participation: Discharge planning.
(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences.
(b) Standard: Discharge or transfer summary content. (1) The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care.
(2) The HHA must comply with requests for additional clinical information as may be necessary for treatment of the patient made by the receiving facility or health care practitioner.
Start Part
PART 485—CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS
End Part Start Amendment Part
6. The authority citation for part 485 is revised to read as follows:
End Amendment Part Start Authority
42 U.S.C. 1302 and 1395(hh).
End Authority Start Amendment Part
7. Section 485.635 is amended by adding paragraph (a)(3)(viii) to read as follows:
End Amendment Part
Condition of participation: Provision of services.
* * * * *
(a) * * *
(3) * * *
(viii) Policies and procedures that address the post-acute care needs of patients receiving CAH services.
* * * * *
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8. Section 485.642 is added to read as follows:
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Start Printed Page 51884
Condition of participation: Discharge planning.
A Critical Access Hospital (CAH) must have an effective discharge planning process that focuses on the patient's goals and treatment preferences and includes the patient and his or her caregivers/support person(s) as active partners in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient's goals for care and his or her treatment preferences, ensure an effective transition of the patient from the CAH to post-discharge care, and reduce the factors leading to preventable CAH and hospital readmissions.
(a) Standard: Discharge planning process. 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.
(1) Any discharge planning evaluation must be made on a timely basis to ensure that appropriate arrangements for post-CAH care will be made before discharge and to avoid unnecessary delays in discharge.
(2) A discharge planning evaluation must include an evaluation of a patient's likely need for appropriate post-CAH services, including, but not limited to, hospice care services, post-CAH extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient's access to those services.
(3) The discharge planning evaluation must be included in the patient's medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient's representative).
(4) Upon the request of a patient's physician, the CAH must arrange for the development and initial implementation of a discharge plan for the patient.
(5) Any discharge planning evaluation or discharge plan required under this paragraph must be developed by, or under the supervision of, a registered nurse, social worker, or other appropriately qualified personnel.
(6) The CAH's discharge planning process must require regular re-evaluation of the patient's condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(7) The CAH must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were readmitted within 30 days of a previous admission, to ensure that the plans are responsive to patient post-discharge needs.
(8) The CAH must assist patients, their families, or the patient's representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The CAH must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences.
(b) Standard: Discharge of the patient and provision and transmission of the patient's necessary medical information. The CAH must discharge the patient, and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient's follow-up or ancillary care.
Start Signature
Dated: August 20, 2019.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.
Dated: September 17, 2019.
Alex M. Azar II,
Secretary, Department of Health and Human Services.
End Signature