The challenges of hospital discharge planning are well known and yet have not been adequately addressed by hospitalists and discharge teams. As the complexity of patient care needs has grown, so has the difficulty in developing appropriate discharge goals for post-acute and long term care (LTC), choosing the appropriate setting(s), and selecting appropriate providers. Post-acute and LTC needs may include rehabilitation, nursing care, home health, supportive services, and/or palliative care1 in an institutional setting or at home from a wide array of providers with varying levels of quality.
Even though 52% of U.S. hospitals received penalties for having higher-than-expected readmissions between 2013 and 2017,2 inadequate discharge planning for post-acute and LTC continues to contribute to high rates of all-cause 30-day rehospitalization. The discharge process sometimes is deficient in: discussion of goals; assessment of discharge needs; appropriate choice of discharge locations; and the provision of additional or different home services.3 Discharge decisions are complicated by the stressful circumstances of hospitalization and discharge deadlines.
Dr. Charlene Harrington
A number of intervention studies have been implemented to improve the discharge planning process including Project RED (ReEngineered Discharge) and Project Boost (Better Outcomes for Older adults through Safe Transitions).4,5 These multifaceted interventions, both pre- and post-discharge, include: institutional self-assessment, team development, stakeholder support, and process mapping. Other policies, practices, and programs have been developed to facilitate transitions after hospitalization,6-8 but they have not focused on the use of currently available post-acute and LTC quality report cards that can augment these interventions.
Hospital discharge planning decisions fall heavily on patients, families, and caregivers, often with inadequate information about choices and options. More than 30 states have passed the Caregiver Advise, Record, and Enable (CARE) Act into law to require hospitals to provide resources for family caregiver education and instruction,7 but hospitals do not have to provide information on all LTC options and provider quality ratings.
Quality report cards about LTC providers – a major innovation for consumer education and choice – are often not used in the discharge process for a number of reasons. A significant concern is that using report cards will extend the length of stay. Rather than extending the decision-making time and the length of stay, the use of report cards can reduce length of stay.9 A focus on identifying the first available nursing home bed or LTC provider often ignores the need to identify the most appropriate high-quality providers.
Dr. Jeffrey Newman
Although individuals on Medicaid and/or with complex medical conditions may have fewer discharge options than other patients, the majority of nursing home providers have low occupancy rates and will accept residents from any payer. Other home- and community-based providers generally have a flexible capacity for serving individuals.
Hospitals and health plans often have established networks of post-acute and LTC providers and these networks must be taken into account in the discharge process. Most hospital and health plan networks have providers with a wide range of ratings, allowing for choices within networks.
The Centers for Medicare and Medicaid Services (CMS) established a web-based nursing home report card called Nursing Home Compare in 1998 that includes information on facility characteristics, deficiencies, staffing information (since 2000), and resident quality indicators (since 2002). In 2008, the website added a “five-star” rating system for all U.S. nursing homes and all-cause 30-day readmission rates and successful discharge rates from nursing homes were incorporated into the ratings in 2016.
CMS also established a web-based home health website, which provides quality ratings. This website has general information, quality measures, and patient surveys with information on readmission rates from home health agency services.
Dr. Leslie Ross
Some states have developed their own information on LTC providers. In California, an integrated single-portal LTC consumer information website is available that includes all licensed LTC providers (about 20,000) including nursing homes, home health, hospice, residential care, and day care (www.Calqualitycare.org). This model website uses public information from federal and state sources on deficiencies, complaints, staff and providers, services, quality measures, provider characteristics, and costs. Ratings, similar to the CMS ratings but with more comprehensive state information, are provided.
After establishment of the CMS Nursing Home Compare rating system in 2008, nursing homes improved their scores on certain quality measures and consumer demand significantly increased for the best (5-star) facilities and decreased for 1-star facilities.10 More recently, a clinical trial of the use of a personalized version of Nursing Home Compare in the hospital discharge planning process found greater patient satisfaction, patients being more likely to go to higher ranked nursing homes, patients traveling further to nursing homes, and patients having shorter hospital stays, compared with the control group.9
Quality report cards show wide variations within and across states ranging from one star (poorest quality) to five stars (highest quality). More than one-third of nursing homes had relatively low overall star ratings (1 or 2 stars) serving 39 percent of residents in 2015.11 Federal nursing home regulatory violations range from zero to more than 40 deficiencies (average of 7) with a scope and severity ranging from minor to widespread harm or jeopardy (including deaths).12 Total nurse staffing hours (average, 4.1 hours per resident day) range from less than 3 hours to more than 5.5 hours per resident day and RN hours are 3.5 times higher in some nursing homes than in the lowest staffed homes.13 Hospital readmission rates for short-stay residents from nursing homes also vary widely (4%-52%; average, 21%).12,14
Hospitalists and discharge planners should inform patients, families, and caregivers about the federal and state LTC quality report cards, provide education and choices, and engage and assist them in the decision making process. Hospitals, health plans, and accountable care organizations also need to be more informed about the availability of and benefits of using quality report cards for developing post-acute and LTC provider networks. The use of high quality LTC network providers should be able to reduce hospital length of stay and hospital readmission rates, and improve patient and caregiver satisfaction.