Western New York Beacon is reviewing the hospital discharge and admission to long-term care facility process in order to determine how HEALTHeLINK, as the RHIO, can improve the efficiency, innovate patient transfer and reduce adverse outcomes. The e-Health Network of Long Island currently has long-term care facilities as part of their HIE.9 Three states (Colorado, Massachusetts and Oklahoma) have ONC funded pilots to connect long-term care facilities to RHIOs. There is a national Coordination of Care Workgroup that is developing standards for transfer of information.10
The Centers for Medicare and Medicaid Services (CMS) requires that all hospitals participating in Medicare/Medicaid services provide a "discharge planning evaluation (that) must include an evaluation of the likelihood of a patient needing post-hospital services and the availability of the services."11 The hospital is also responsible for arranging for the initial implementation of the discharge plan, once developed. A listing of community-based services, long-term care, sub-acute care, home care and other services and levels of care must be maintained by the hospital. Discharge plans for patients in need of skilled nursing typically include the following elements:
- Primary language;
- Family members/notification of discharge;
- Primary diagnoses;
- Medications (including immunizations and reconciliation review);
- Advance directives;
- Mental status;
- History of falls;
- Skin integrity;
- Assistive/protective devices (i.e., hearing aids, glasses, walkers, etc.);
- ADL status;
- Special instructions;
- Belongings sent; and
- Followup care.
Additional information that is often included is:
- Pain score;
- Last vital signs (BP, pulse, respiration, temperature);
- Time of last medication(s); and
- Patient/Family preferences for care.
While all of these elements would be useful, and some vital to the ongoing care of the patient, there is currently no national standards or requirements for hospitals as to what is essential to be included in the discharge plan.12
According to a study done in 2000, American adults aged 65 and older experience 200 hospital admissions and 46 nursing home admissions per 1,000 persons annually.13 Recent Medicare studies show that of those Medicare patients hospitalized, close to 20% will be rehospitalized within 30 days, often due to lack of communication and missing information at the time of discharge to another facility.14
Currently, the hospital discharge process starts as early as date of admission. Hospitals receiving Medicare/Medicaid payments or Joint Commission accredited are required to provide discharge plans for each patient. Almost all hospitals have a dedicated department for discharge planning/patient care management, usually staffed by nurses and/or medical social workers. This staff works closely with the doctors and other members of the care team, to facilitate patient discharge. Responsibilities include:
Assuring all patient assessments are completed prior to discharge, including psycho/social assessments, ADLs, patient ongoing needs.
Finding appropriate followup care, including LTPAC and home care.
Interviewing patients/family members for preferences.
Problem lists, medications (including reconciliation), immunizations, allergies.
Communication with the patient and family members of what to expect, warning symptoms, contact information.
Summary of care provided by the hospital.
Compilation of all required documents to be provided to the receiving facility.
The receiving facility needs to evaluate patients to be transferred in order to identify areas of concern and assure discharge care plan will meet the patients' needs and can be implemented in a timely manner. Once the need for LTPAC has been made, the discharge planner will meet with the patient and family members to describe this need and determine preferences. The discharge planner must then try and determine if there is care available at preferred sites and if not, discuss alternatives with the patient and family. This marks the beginning of shared patient information between the hospital and long-term care facility. The long-term care facility needs several key elements in order to determine bed availability for a patient (gender, problem list, ADL status, cognitive status, psycho/social status, assistive devices, IV needs, etc.). Once the long-term care facility has enough information to determine bed availability, they can accept the referral and the discharge planner can proceed with final discharge arrangements. Currently, this process takes place by phone and paper.
The Health Insurance Portability and Accountability Act (HIPAA) allows for access to information on a "need to know" basis, allowing for transitions of care to qualify as need. HEALTHeLINK' s current consent policy provides for level 1 and level 2 access; level 1 for treatment, quality improvement, care management and insurance coverage (preauthorization) reviews. Care Management is defined as:
"(i) assisting a patient in obtaining appropriate medical care, (ii) improving the quality of health care services provided to a patient, (iii) coordinating the provision of multiple health care services to a patient or (iv) supporting a patient in following a plan of medical care. Care Management does not include utilization review or other activities carried out by a Payer Organization to determine whether coverage should be extended or payment should be made for a health care service."15
The discharge of a patient from a hospital to a long-term care setting qualifies on all four of these counts.
Several Beacon projects are already automating the discharge process from hospital to long-term care settings and meeting with great success. The Colorado RHIO is already reporting a reduction in the amount of time for discharge processing from an average of 35 hours 21 minutes, pre-HIE, to 25 minutes average time post-HIE, a savings of almost 35 hours in the process. In addition, they report that 70% of the care transitions data is exchanged electronically and 70% is exchanged within the targeted number of hours.16 Massachusetts and Oklahoma are also reporting early successes using HIE for the exchange of needed data between hospitals and long-term care facilities. The process is similar:
- Hospital (Data Sender) records required pt. data elements in HIE or Community Health record;
- Hospital sends electronic referral notice to skilled nursing or long-term care facility;
- SNF admissions gets referral and accesses patient data on HIE to review and accept referral; and
- Information now available electronically for core users and Doctor at SNF.
There is precedence in New York State for long-term care facilities to be connected to a RHIO that include hospitals. The following long-term care facilities share information through e-Health Network of Long Island: Bellhaven Center for Rehabilitation and Nursing Care; Cedar Lodge Nursing Home; Eastern Long Island Hospital; Grace Plaza Nursing and Rehabilitation Center; Hilaire Rehab and Nursing; Long Island State Veterans Home; Nassau Extended Care Facility; Nesconset Nursing Center; Peconic Bay Medical Center; Peconic Bay Skilled Nursing and Rehabilitation Center; Physician Offices in Suffolk and Nassau Counties; San Simeon by the Sound Center for Nursing and Rehabilitation; Southampton Hospital; St. James Healthcare Center; Stony Brook University Medical Center; Suffolk County Department of Health Services; Winthrop University Hospital; Woodhaven Adult Home; and Woodhaven Nursing Home.
Next Steps for HEALTHeLINK
In order for HEALTHeLINK to achieve similar successes, the following would be needed:
- Assess hospital capabilities to transmit electronic discharge data elements;
- Assure interfaces are set up to send to HIE;
- Provide assistance on HIE access and training to hospital discharge planning staff;
- Set up electronic referral process (could be done later in the process and continue current notification process); and
- Set up admissions coordinator for HIE access and provide assistance and training.
Working with several state HIEs, ONC is studying "ways in which HIE can improve care coordination and transitions of care with LTPAC providers and the patients and caregivers they serve." With the goals of "Increasing the ability of providers, patients and caregivers to view/download/transmit timely, accurate information through HIE during transitions (and) reducing adverse events -- hospital readmissions, medication errors." These goals align with HEALTHeLINK's own mission and vision and are the logical next steps for the organization.
Longitudinal Coordination of Care (LCC) Workgroup, http://wiki.siframework.org/Longitudinal+Coordination+of+Care+WG.
CMS Code of Federal Regulations (CFR), 482.43 (b)(3).
National Citizens' Coalition for Nursing Home Reform: Annual Meeting notes October 23, 2009.
Gabrel CS, Jones A. The National Nursing Home Survey. Vital Health Statistics 13, 2000; 147: 1-121.
Rau, J. Medicare to Penalize 2,217 Hospitals for Excess Readmissions. Kaiser Health News. October 12, 2012.
HEALHeLINK Policy #P04 Patient Consent -- current revision August 23, 2010, and HEALTHeLINK Glossary of Terms -- Care Management.
Office of the National Coordinator. Inaugural Meeting: Long-Term and Post-Acute Care Community of Practice (COP). January 23, 2013.
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