Transitional Planning

Jackie Birmingham

LEARNING OBJECTIVES

Upon completion of this chapter, the reader will be able to:

Define transitional planning.
Differentiate between transitional planning and discharge planning.
List the key federal Conditions of Participation that influence transitional and discharge planning in an acute care setting.
Discuss the role of the case manager in the process of transitional planning.
- Role of provider-based case manager
- Role of payer-based case manager
- Role of case manager in post-acute settings such as nursing facilities, home health agencies, and inpatient rehabilitation facilities
List and describe selected levels of care that make up the continuum of care.
- Conditions of Participation for all levels of care
Discuss transitional planning resources for case managers.
- Joint Commission on Accreditation of Health Care Organizations (JCAHO)
- American Osteopathic Association (AOA)
- Case Management Adherence Guidelines (CMAG)
- National Guidelines Clearinghouse (AHRQ—Agency for Healthcare Research and Quality, Department of Health and Human Services)

INTRODUCTION

The concept of transitional planning is based on “continuity of care.” Case management and the process of transitional planning are relatively new concepts in health care delivery. Prior to the implementation of payment methods that influenced where and when health care services were delivered, the primary setting of health care delivery for persons with active health problems was in a hospital, and those with chronic diagnoses depended on physician office visits. As the post-acute health care delivery system developed into a viable alternative to acute care, the movement of patients between levels increased. Navigating through the acute to post-acute and chronic-acute to post-acute system was, and is, very complex. Case management grew out of this phenomenon as a way to help transition patients from one level of care to another while maintaining quality of and access to needed services, while simultaneously managing costs.

KEY DEFINITIONS

A. Conditions of Participation— The Centers for Medicare and Medicaid Services (CMS) develops Conditions of Participation (CoPs) that health care organizations must meet to participate in the Medicare and Medicaid programs. These standards are used to improve quality and protect the health and safety of beneficiaries. The CMS also ensures that the standards of accrediting organizations recognized by the CMS, such as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) or the American Osteopathic Association (AOA), through a process called deeming, meet or exceed Medicare standards as stated in the CoP. The standards apply to anyone receiving services, regardless of payment source.

Discharge planning—CoPs are associated directly with the hospital’s responsibility for discharge planning.
Patients’ rights—CoPs are associated with assuring that patients’ rights to freedom of choice and other issues are followed.
Medical records—CoPs are associated with the patient’s inpatient medical record and the need to ensure that the closed record contains information related to the course of the hospital stay and plans for follow-up care.

B. Continuity of care—The coordination of care received by a patient over time and across multiple health care providers and settings.

C. Discharge—The formal release, or signing out by a physician, of a patient from an episode of care. The episode of care can be from hospital inpatient status, observation status, or emergency room stay. A discharge can also be applied to an inpatient skilled nursing facility, acute and sub-acute rehabilitation facility, or a home health episode of care.

Discharge status—Disposition of the patient at discharge indicating to what level of care a patient has been transferred or discharged. Discharge status, particularly from acute care, has significance in how a hospital is paid, and in how health care organizations track care. Because of this, there are specific codes that are assigned to the various types of dispositions (Table 10-1).
Leaving Against Medical Advice (LAMA) or Against Medical Advice (AMA)—A term used to describe a patient who is discharged from the hospital against the advice of his or her attending physician. The person signing out is usually asked to sign a form stating his or her awareness that the discharge is against medical advice.
Patient elopement—A term used to describe a situation in which a patient leaves without the knowledge of the hospital staff. The patient is then determined to be “missing.”

D. Discharge planning—The process of assessing the patient’s needs of care after discharge from a health care facility and ensuring that the necessary services are in place before discharge. This process ensures a patient’s timely, appropriate, and safe discharge to the next level of care or setting, including appropriate use of resources necessary for ongoing care (CCMC, 2005).

E. Functional status—The assessment of an individual’s ability to manage his or her own care needs.

Activities of daily living (ADL)—Activities that are considered an everyday part of normal life. These include dressing, bathing, toileting, transferring (e.g., moving from and into a chair), and eating. The functional levels of ADLs are used to measure the degree of impairment and can affect eligibility for certain types of insurance benefits.
Instrumental activities of daily living (IADL)—Regularly necessary home management activities, including meal preparation, housework, grocery shopping, and other similar activities.
Executive function—An integrated set of cognitive abilities that allow an individual to process available information in planning, prioritizing, sequencing, self-monitoring, self-correcting, inhibiting, initiating, controlling, or altering behavior. It includes evaluation of such parameters as “capacity” and “competency.” Evaluating a patient’s executive function is a multidisciplinary process involving physicians, nurses, social workers, and other health care professionals and can, in some situations, involve the court system (Cooney et al., 2004).

TABLE 10-1 Disposition Codes Used at the Time of Discharge

Code	Description
01	Discharged to home or self-care (routine discharge). Includes: discharged on home oxygen or home DME services (without home health), court/law enforcement, residential care, foster care.
02^*	Discharged/transferred to a short-term general hospital for inpatient care. Use this code to bill a same-day transfer claim for an inpatient claim. The “from” and “through” dates in the statement coverage period (FL6) must be the same. Use condition code 40—same-day transfer (FLs 24-30), and show the one day as noncovered in FL 8 with the noncovered charges reported in FL 48.
03^†	Discharged/transferred to SNF with Medicare certification in anticipation of covered skilled care (effective 2/23/05). Indicates that the patient is discharged/transferred to a Medicare-certified skilled nursing bed and qualifies for skilled care (regardless of whether the patient has skilled benefit days). For hospitals with an approved swing bed arrangement, use Code 61—swing bed. For reporting transfers to nursing facilities see 04 and 64.
04	Discharged/transferred to an intermediate care facility (ICF). Typically defined at the state level for specifically designated intermediate care facilities. Also used to designate patients who are discharged/transferred to a nursing facility with neither Medicare nor Medicaid certification and for discharges/transfers to state-designated assisted living facilities. For transfers to dual-certified facilities, confirm level of care with physician/discharge planner, i.e., skilled (03), hospice (50/51), or intermediate care (04).
05^†	Discharged/transferred to another type of institution not defined elsewhere in this code list (effective 2/23/05). Cancer hospitals excluded from Medicare PPS and children’s hospitals are examples of such other types of institutions. Includes: chemical dependency treatment facility that is not part of a hospital; patient transferred from hospital-based SNF to observation; discharge from acute care to another acute care facility for outpatient procedure with intention that patient will not be returning to the first acute care facility following the procedure.
06^†	Discharged/transferred to home under care of organized home health service organization in anticipation of covered skilled care (effective 2/23/05). Report this code when the patient is discharged/transferred to home with a written plan of care for home care services.
07	Left against medical advice or discontinued care. Effective April 1, 2004, these claims are treated as transfers if the patient is subsequently admitted to another inpatient PPS hospital on the same day. Medicare PM A-03-073, August 22, 2003.
20	Expired. (Or did not recover—Christian Science patient.)
43	Discharged/transferred to a federal hospital (VA hospital). Use whenever the destination at discharge is a federal hospital, whether or not the patient lives there.
50	Discharged to hospice—home
51	Discharged to hospice—medical facility
61	Discharged/transferred to a hospital-based Medicare-approved swing bed
62^†	Discharged/transferred to a rehab facility, including rehabilitation unit as distinct part of a hospital
63^†	Discharged/transferred to a long-term care hospital (Long-term hospitals provide acute inpatient care with an average LOS >25 days, provider numbers include XX2000-XX2299.)
64	Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare. Acute care hospitals, SNFs, outpatient hospital providers are required to report this code, if appropriate, although the use of this code does not impact payment.
65^†	Discharged/transferred to a psychiatric hospital or psychiatric unit as distinct part of a hospital
66	Discharged/transferred to a critical access hospital (effective for discharges after 1/1/06).
^*Each transferring hospital is paid a per diem rate, not to exceed the full DRG payment that would have been made if the patient had been discharged without being transferred.^†Affects reimbursement if assigned to one of 182 select DRGs.
From Centers for Medicare & Medicaid Services (CMS) (2005). Completing and processing the form CMS-150 data set. In Medicare claims and processing manual (Chap. 25). Retrived from http://www.cms.hhs.gov/manuals/downloads/clm 104c25.pdf

F. Handoff—The exchange of a patient’s care between incoming and outgoing caregivers; any transfer of role and responsibility from one person to another or one setting to another. Successful handoffs overcome barriers such as physical setting, social setting, language and communication barriers, and time and convenience (Solet et al., 2005).

G. Level of care—Different kinds and locations of care provided to patients, based on a scale of intensity or amount of care/services provided.

Acute level of care—The most intense level of care related to necessity for medical (physician) services.
Sub-acute level of care—The level of care that combines a high need for nursing, therapy, and physician services. Intermediate between acute and chronic, this level of care can be provided in acute care facilities or other facilities as determined by licensing in each state.
Transitional care unit (TCU)—A unit of care, usually in a hospital, that is dedicated to supporting a patient’s transition of care from acute to a lesser level of care. The level of care is similar to sub-acute.
Skilled nursing facility (SNF)—A facility offering 24-hour skilled nursing care along with rehabilitation services, such as physical, speech, and occupational therapy; assistance with personal care activities, such as eating, walking, toileting, and bathing; coordinated management of patient care; social services; and activities. Some nursing facilities offer specialized care programs for Alzheimer disease or other illnesses, or short-term respite care for frail or disabled persons when a family member requires a break from providing care in the home. Payment for a stay in an SNF varies depending on the payer criteria, whether the patient was an inpatient in a hospital for 3 consecutive days, and the reason for admission.

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