Jan. 4, Dear Acting Administrator Slavitt:

Transcription

1 Providence Health & Services Valley Office Park 1801 Lind Avenue S.W., #9016 Renton, WA Jan. 4, 2016 Andrew M. Slavitt Acting Administrator Centers for Medicare and Medicaid Services Department of Health and Human Services 7500 Security Blvd Baltimore, MD Re: Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies Dear Acting Administrator Slavitt: On behalf of Providence Health & Services, thank you for the opportunity to provide feedback to the Centers for Medicare & Medicaid Services proposed rule revising discharge planning requirements for hospitals, critical access hospitals (CAHs), and home health agencies (HHAs) published in the Federal Register on Nov. 3, Providence Health & Services is a not- for- profit Catholic health care ministry committed to providing for the needs of the communities it serves especially for those who are poor and vulnerable. The comprehensive scope of services at Providence includes 34 hospitals, 475 physician clinics, home health and hospice, senior services, supportive housing and many other health and educational services. The health system and its affiliates employ more than 76,000 people across five states: Alaska, California, Montana, Oregon and Washington. As a large, integrated health care system providing services to patients across the continuum of care from primary to acute care to home health and hospice we are committed to clinical excellence with compassion. We know that quality of life improves when individuals and families have broad access to high- quality, patient- focused, affordable care. Together, Providence ministries and secular affiliates are working at scale to improve overall health in every community we serve through innovation in care delivery, new economic models and expert- to- expert collaboration. The discharge planning process plays important role in providing high quality care for patients, engaging patients and families in care planning and decisions, and lowering health care costs. We share many of CMS goals and appreciate the opportunity to offer the following feedback for your consideration.

2 Discharge planning process for hospitals, home health agencies, and critical access hospitals In the proposed rule, hospitals, home health agencies (HHA), and critical access hospitals are required to assist patients with selecting a post- acute care (PAC) provider by using and sharing data on home health agency, skilled nursing facility, and long- term care hospital quality and resource use measures. In addition, hospitals, HHAs, and CAHs must document that the data were shared with patients and be available to explain the data. Post acute care decisions are the product of consultation between the patient/family, hospital physician, community physician and the availability of PAC providers. While we recognize the value in utilizing data on quality and resource use measures as a basis for selecting a PAC provider, we are concerned that this may lead to greater delays in discharges and increase frustration for patients. The most convenient and available option may be an entity with low scores; alternatively, an entity with high scores may not accept the patient. It is also important to note that the proposal necessitates education on how to interpret quality and resource use measures and scoring in order to engage patients and their caregivers in post- discharge decision- making. In considering the operational challenges of creating patient- friendly materials, we are also concerned about the burden of compiling quality and resources use measures and ensuring that materials are up to date. Providence recommends that CMS identify specific measures from the Home Health Compare and Nursing Home Compare websites to be used for post- discharge decisions and make improvements to these CMS websites to aid providers in easily printing the necessary fields and educational, explanatory materials for patients and families. Such improvements in the CMS site will ease the operational burden for all providers and provide uniform educational tools for physicians, beneficiaries and their caregivers on how to interpret and use these measures to make the best possible decision. In addition, we also ask that CMS recognize that some beneficiaries may have a preferred post- acute provider. A discharge planning process that requires hospitals and HHAs to share this information, irrespective of the patient s wishes, may make beneficiaries feel as though they are not being heard and respected. We recommend that CMS clarify the proposal to allow for a patient opt- out. Requirements for hospital discharges to home The proposed rule states hospitals must establish a post- discharge follow up process for patients discharged to home. We noted that CMS does not specify the mechanisms or timing of the follow- up program. We ask that CMS clarify that a hospital s follow up process does not need to be restricted to hospital- based practitioners and may be initiated by community- based primary care teams. The proposed rule would require that hospitals send a copy of discharge instructions and summary within 48 hours of discharge to the follow up care practitioners. In addition, it requires pending test results be sent to follow up care practitioners within 24 hours of their availability. Providence supports the intent behind coordinating care and sharing information with community providers. However, we note that our hospitals that have achieved Stage 2 of meaningful use do not

3 have the capability to transmit summary of care information to all community providers. In some cases, we are still establishing electronic connections, and in others, community providers have not yet achieved Stage 2 of meaningful use and do not have the capability to receive this information. Providence recommends that CMS align these requirements with the EHR Incentive Program objectives and measures so that hospitals are not burdened with creating a work around, but rather, focused on building the electronic networks and connections necessary for the future. CMS also noted in the proposal that hospitals are encouraged to consult with their state s prescription drug monitoring program (PDMP) and sought comments on whether practitioners should be required to consult with their state's PDMP to reconcile patient use of controlled substances as documented by the PDMP, even if the practitioner is not going to prescribe a controlled substance. Providence is concerned that state PDMPs are not equipped for a large influx of consultation requests and such a requirement could delay discharges. In the future, an automated, electronic query to a PDMP may ease some of these operational burdens, but is premature at this time. Transfer of patients to another health care facility CMS proposes to establish a new standard that hospitals, HHAs, and CAHs send necessary medical information to the receiving facility or health care practitioner. This new standard would include a broad set of information, including demographic, contact for the physician responsible, laboratory tests, reconciliation of all discharge medications and other items. Providence supports this proposed new standard. In our view, ensuring this level of detailed information is made available to receiving facilities and/or practitioners will improve care continuity and quality for Medicare beneficiaries and supports the goal of reducing preventable hospital readmissions. However, we are concerned about the proposed requirement that hospitals, HHAs, and CAHs provide unique device identifier(s). This information only became part of the common clinical data set in the 2015 Edition health information technology certification criteria. Providence recommends that CMS delay the implementation date by months to allow time for EHR vendors to update systems to comply with the common clinical data set in the 2015 Edition health information technology certification criteria. Furthermore, we ask that CMS clarify the requirement to provide unique device identifier(s) for new device(s) because such information may not be available for all devices. In addition, we are concerned that requiring home health agencies to include laboratory tests and the results of pertinent laboratory and other diagnostic testing in the summary will be difficult to achieve, as in many cases these tests and results are not included in the electronic medical record. We recommend that the CMS clarify the requirement to include only those tests performed during the home health episode of care by the home health agency. Critical Access Hospital Discharge Planning As noted by CMS in the proposed rule, the current condition of participation for CAHs do not currently include discharge planning requirements. As such, CMS proposes to establish essentially the same

4 discharge planning standards for both prospective payment system (PPS) hospitals and critical access hospitals. With respect to the proposed new standards for CAHs, Providence strongly supports CMS efforts to ensure that an effective, patient- centered discharge planning process is in place for all patients. We agree with CMS statement that due to the availability of fewer resources in a rural environment, it is important to keep CAH patients on the path to recovery by ensuring that the CAH effectively communicates the discharge plan to the patient and those who will be providing support to the patient post- discharge. Moreover, we support CMS proposal require largely the same standards for both PPS hospitals and CAHs. However, Providence does have some concerns regarding proposed elements of the standard in which there is either need for clarification or modification given the distinct differences between CAHs and PPS hospitals. These are: 1) Greater clarity regarding which ED or same- day/surgery patients are applicable for discharge plans to ensure consistency among state surveyors; and 2) Limited staffing for discharge planning during weekends. Applicability for outpatients CMS proposes that discharge plans would be required for patients undergoing surgery or same- day procedures where anesthesia or moderate sedation is used, along with ED patients identified as needing a discharge plan. While Providence supports including these categories of patients as applicable for discharge plans, we recommend the agency provide greater specificity on the definitions of these patients to ensure that there is less variability in interpretation by hospital surveyors. Discharge planning process CMS proposes that discharge planning must begin 24 hours after admission or registration and must be completed prior to being discharged or transferred. In addition, CMS proposes to require that if a patient stay is less than 24 hours, discharge needs must be identified before discharge or transfer. Providence is concerned that because of limited staff resources, many CAHs do not schedule discharge planners on duty during weekends, nor are there currently staff trained to educate patients on how to interpret quality and resource measures for the purposes of choosing a post- acute care provider. We recommend that CMS establish an exceptions policy for such circumstances and to clarify when exceptions may be allowed. Behavioral health focus CMS notes in the proposed rule that hospitals and CAHs are expected to arrange, as applicable, for the development and implementation of a specific psychiatric discharge plan for the patient as part of the patient s overall discharge plan; and coordinate with the patient for referral for post- acute psychiatric or behavioral health care. While we strongly support focusing on behavioral health, this requirement will

5 not address the severe shortage in behavioral health care providers that we face in every community we serve. We are concerned that this proposal may exacerbate current challenges and further delay patients discharges due to an inability to locate a behavioral health provider able to accept a post- discharge referral. Thank you for the opportunity to provide comments on this important proposed rule. We hope that you find our input informative. For more information, please contact Christa Shively, director, federal regulatory affairs and engagement, at (503) or via at christa.shively@providence.org. Sincerely, Rod Hochman, MD President and CEO Providence Health & Services