As skilled nursing facilities and home health agencies work to assess and admit new residents and patients, they often face the challenge of obtaining all of the information about the individual to make a proper admission assessment and to begin to build a care plan designed specifically for the individual. When a patient is discharged from acute care, it is important that the acute care provider deliver accurate and appropriate patient information related to a patient’s treatment and condition in order to decrease the risk of readmission or an adverse event at the skilled nursing providers and home health agencies. On June 6, 2023, the Centers for Medicare & Medicaid Services (“CMS”) released guidance on requirements for proper discharges from acute care to skilled nursing providers and home health agencies (“CMS Memo”).
The CMS Memo gives skilled nursing providers and home health agencies a playbook focused on the information to obtain and receive when a patient is discharged from acute care, including:
Behavioral Care Needs
The CMS Memo emphasized that skilled nursing providers and home health agencies admitting patients with serious mental illness (“SMI”), complex behavioral needs and/or substance use disorder (“SUD”) need the individual’s information related to the patient’s underlying diagnoses of SMI and/or SUD. Additionally, post-acute care providers need to ensure acute care providers share the specific treatments that were implemented to help manage these conditions while in the hospital, such as additional supervision that was provided throughout the patient’s hospital stay or was provided for some of the hospital stay, but discontinued prior to discharge (e.g., 24-48 hours before being discharged).
Medication Needs
The CMS Memo highlighted that medication information is a key admission item that skilled nursing facilities and home health agencies need to obtain from acute care providers. Specifically, they need to obtain a comprehensive list of all medications that have been prescribed to a patient during and prior to their hospital stay.
Skin/Wound Care Needs
The CMS Memo emphasized that skilled nursing facilities and home health agencies obtain information from acute care providers regarding the individual’s skin tears, pressure ulcers, bruising or lacerations, including orders or instructions for cultures, treatments or dressings.
Medical Equipment Needs
Durable medical equipment is a crucial admission element for post-acute providers. The CMS Memo emphasized that providers obtain information from acute care providers on durable medical equipment, oxygen needs for respiratory treatments, skin healing equipment and the patient’s equipment needs for wound care.
Personal Preferences and Goals
The CMS Memo also emphasized that post-acute providers receive information on a patient’s personal preferences and goals for care. This information includes the individual’s choices for treatment and end-of-life care goals.
Caregiver Needs – Home Care
Another area of emphasis in the CMS Memo is that providers often do not receive information about a patient’s needs at home or how their home environment may impact their ability to maintain their health and safety after discharge from acute care to a home health agency.
Practical Takeaways
- Skilled nursing facilities and home health agencies should work with acute care case managers and discharge planners to review the information provided at the time of discharge to post-acute care.
- Skilled nursing facilities and home health agencies should revisit their admission policies and procedures on the information gathered from acute care providers.
- Skilled nursing facilities and home health agencies should educate and train their staff to ensure that accurate information is obtained from acute care providers.
- Skilled nursing facilities and home health agencies need to document all of their efforts taken to facilitate obtaining this information from acute care providers.
Should you have any questions about this topic or how to update your policies and procedures or would like a set of policies and procedures, please contact:
- Sean Fahey at (317) 977-1472 or sfahey@hallrender.com;
- Brian Jent at (317) 977-1402 or bjent@hallrender.com;
- Todd Selby at (317) 977-1440 or tselby@hallrender.com; or
- Your primary Hall Render contact.
More information about Hall Render’s Post-Acute and Long-Term Care services can be found here.
Hall Render blog posts and articles are intended for informational purposes only. For ethical reasons, Hall Render attorneys cannot give legal advice outside of an attorney-client relationship.
