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Volume 3, Issue 19 | March 22, 2022
Highlights of Outreach and Collaborative Efforts of the
Beneficiary and Family Centered Care - Quality Improvement Organization (BFCC-QIO)
The Livanta Compass. Supporting patients and families in their healthcare journey.
Supporting the Healthcare Journey with Effective Discharge Planning
Last week’s issue of The Livanta Compass covered the critical role of social workers in a patient’s healthcare journey. Social workers are an integral part of patient recovery from illness and injury and help address a range of issues to support patients in achieving the best possible health outcomes. With a broad knowledge base of medical concepts and keen insight into resources available from the local community, social workers and other discharge planners, who are often nurses, help patients prepare for the next step in their journey. Together, the members of the discharge planning team help ensure that a discharge plan is complete from both clinical and social services perspectives.
This week’s issue of The Livanta Compass examines the importance of discharge planning and the effects that it can have on a patient’s health outcomes. 
To Be (or Not To Be) Hospitalized
Patients can be admitted to a hospital for several reasons, such as for treatment of serious or life-threatening injuries or medical conditions, or for less serious conditions that require treatment or monitoring that only a hospital can provide. In many cases, adverse health outcomes or even death could result without emergency interventions or acute care provided by the hospital.
A common misconception among patients is that, once they are in the hospital, they will not be discharged until they are feeling “well enough” to go home. However, in today’s highly-regulated environment, care is provided at each level only for as long as it is needed. Inpatient care received at the hospital is intended to stabilize patients and prepare them for the next appropriate level of care—even if the patient is still feeling unwell. Indeed, many patients are not aware that significant portions of their recovery are intended to happen outside of the hospital. For example, it is common for laboratory blood tests to be ordered after the patient is discharged home. The patient does not need to stay in the hospital for blood work to be monitored closely by the physician.
When patients are discharged from the hospital or transitioned to another care setting, the discharging hospital or care provider should develop a discharge plan that guides this transition process. The Administration for Healthcare Quality and Research (AHRQ) defines hospital discharge planning as “…the process of identifying and preparing for a patient’s anticipated health care needs after they leave the hospital.”
Effective discharge plans provide the framework for patients to take the next steps in their recovery by helping to summarize and reinforce their instructions for ongoing treatment. Discharge plans often include the following elements:

  • A list of medications, doses, and instructions;
  • Follow-up appointments with primary care doctors, specialists, clinics, or other providers;
  • Prescriptions for new medications or durable medical equipment;
  • Orders and paperwork to complete laboratory work or other tests or procedures; and
  • Other factors that are critical to the patient’s recovery.
AHRQ’s “Care Transitions from Hospital to Home: IDEAL Discharge Planning Implementation Handbook” sets out a step-by-step method for care providers to develop an effective discharge plan. AHRQ created IDEAL, which stands for Include, Discuss, Educate, Assess, and Listen to be used as a stand-alone resource or in conjunction with other initiatives, such as Reengineering Discharge (RED) and Better Outcomes for Older Adults Through Safe Transitions (BOOSTing Care Transitions).
AHRQ, “Care Transitions from Hospital to Home: IDEAL Discharge Planning Implementation Handbook”
CMS, “Data Navigator Glossary of Terms”
Discharge Plans - The Patient's Instructions
Depending on the care setting and the patient’s needs, discharge plans often include medication instructions, diet orders, instructions for follow-up appointments, and other care needs. For example, a discharge plan should list the physician orders for new medications or other changes in the patient’s drug regimen, reminders about follow-up appointments with primary care physicians or specialists, written orders for bloodwork or other monitoring tests, outpatient therapies and other treatments, and any other special instructions. Unfortunately, when these plans are not followed, negative health outcomes may result.
In many cases, patients and caregivers may not fully understand the information presented to them. Discharge plans sometimes use complex healthcare jargon that can be difficult for patients and caregivers to decipher. This is problematic because when patients and caregivers don’t understand discharge instructions, they are less likely to follow them, which can negatively affect a patient’s health outcomes and cause preventable hospital readmissions.
Even if patients understand the discharge plan, they may have other barriers that interfere with being able to adhere to the discharge plan. For example, a patient with congestive heart failure who does not have a bathroom scale will not be able to weigh himself as ordered by the doctor. Patients who do not have financial resources, family, or other sources of social support may have a harder time overcoming such barriers. Over the years, however, progress has been made to help patients better coordinate their care.
HRSA, “Health Literacy”
Patient Resource - Medicare's Discharge Planning Checklist
Your discharge planning checklist
Because discharge planning is essential for patients to continue their recovery, ensuring they understand the plan is vital. This checklist is for patients and caregivers to use. It is designed to help them understand each step, ask questions throughout the planning stage, and make notes. Medicare advises using this checklist early in the discharge planning process.
To download the checklist, click here:
Post-Discharge Care Coordination
Traditionally, the primary care physician is the central point of a patient’s care, as the practitioner who knows the patient’s full medical history and generally helps with recovery from acute illness or injury and manages the overall care. Ideally, a patient’s primary care provider is connected to the hospital and other care settings in the local community. Models such as the Accountable Care Organization (ACO) and Accountable Health Community (AHC) exist to ensure that there is coordination between all levels of care.
An ACO is a network of physicians, hospitals, and other medical providers and/or healthcare organizations that voluntarily collaborate in the care of their common patients, with the goal of advancing the triple aim of better health, better care, and lower cost. These healthcare providers are usually located within a given geographic area and work together to ensure that the delivery of medical services to patients is coordinated and efficient.
Like ACOs, AHCs play a role in coordination of services across a geographic community. However, whereas ACOs focus on coordination of healthcare services for Medicare beneficiaries within a community, AHCs focus on coordinating community services that support the overall health of beneficiaries. Originally created by CMS in 2017 as a five-year pilot program, the AHC program’s website contains several resources and reports and other useful information.
Discharge Appeals and Immediate Advocacy
Receiving an unexpected discharge or service termination notice can often throw a patient and their family into panic. In many cases, when a patient is being discharged home, the family or caregivers may not have expected the patient to return home so soon. Modifications such as wheelchair ramps or bathtub grab bars may need to be made to the patient’s home to ensure a safe transition.
When there is disagreement between Medicare beneficiaries and the discharging facility, beneficiaries the right to file an appeal with the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO). As a BFCC-QIO, Livanta contracts with the Centers for Medicare & Medicaid Services (CMS) to provide congressionally-mandated assistance and quality protection to Medicare beneficiaries.
Smiling man with headphones working in call center
According to Medicare guidelines, all beneficiaries who are admitted to an inpatient hospital have the right to appeal a decision to end Medicare coverage at that level of care (also known as a “discharge decision”). The same appeal rights are provided to Medicare patients receiving skilled nursing, hospice, comprehensive rehabilitation, or home health services when the decision to end Medicare coverage for these services at that level of care has occurred.

When patients or representatives call Livanta’s Medicare helpline to initiate appeals, Livanta staff obtain patients’ medical records and begin the review process. The majority of these cases are completed within 24 to 48 hours. Additionally, Livanta’s Immediate Advocacy Team may be able to mediate and resolve the patient’s concerns about their pending discharge. To learn more about Livanta’s Immediate Advocacy program, visit the website here:
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