Featured speakers: Joshua Abrams Senior Attorney, Mass. General Brigham; Meg Cosgrove, Senior Associate General Counsel, Beth Israel Lahey Health; and Dianne Yacovone, Associate General Counsel, Boston Medical Center
Abrams, Cosgrove, and Yacavone addressed the Massachusetts Health and Hospital Association’s Healthcare Legal Compliance forum in December 2022. This recap of their remarks looks at current challenges in patient discharge rules and practices given the shortage of nursing facilities and challenging patient situations.
While some patients delayed getting care during the pandemic others face new medical situations because of it, creating shortages in some healthcare settings.
A panel of healthcare general counsel tackled these questions and more at the Massachusetts Health and Hospital Association’s Healthcare Legal Compliance forum in December 2022.
Cosgrove noted that people are presenting to the hospital much sicker than they would have previously. The explosion of Covid and flu cases emergency departments in late 2022 has made ERs even more crowded. There has been a collapse in outpatient and community-based supports for a lot of people, she said, and staffing shortage at nursing facilities continue. She said it was bad before the pandemic, and it’s worse now. Add to that: emergency departments are over capacity, so they end of admitting people to the hospital they wouldn’t typically. There simply isn’t a better option.
One way to limit discharge issues is to be sure to admit only people who truly need to be admitted, according to Abrams. This starts with the ER triage process, where patients who don’t need to be seen in the emergency room are given guidance on other options. From there, his colleagues try to resolve health concerns in the ER rather than admitting. It’s important to resolve the emergency and move people out.
“Once you decide to admit someone, you have the overlay of Medicare requirements that impact the ability to discharge the patient.” – Joshua Abrams
While the standard for discharge plans is “safe and appropriate,” Abrams also adds “achievable.” Yacavone noted that while there is always a “best” option, sometimes you have to also look at what can actually happen upon discharge. This is especially true when the patient doesn’t have a surrogate decision maker or lacks the capacity to apply for state aid.
Her team works to secure conservatorship for patients like this – either for a family member or the hospital. That way the hospital can discharge the patient to a skilled nursing facility (SNF) or other more appropriate setting. She works with a cross-functional team to streamline the process of identifying cases, working with outside counsel, and moving the process along.
Providing this support is helpful when family members aren’t engaged, when they don’t know how the process works and avoid the discharge conversation all together.
When a hospital finds a bed in an SNF and the patient or a conservator is able to approve it, there can be another challenge. The patient or surrogate may not like the available SNF. Abrams and Cosgrove both talked about issues surrounding sign-off. The patient or family may have a specific SNF in mind, or they may not like the reputation of the one that’s available. Staffing shortages and longer SNF stays make it harder for people to get the facility they want. And it means hospitals have to make really hard calls, because they have sick patients in the ER who need the beds.
Cosgrove suggested reminding people of the risks of staying in the hospital, especially infection. She also suggested that the care team rely on any preferred providers the family has responded well to. They may be more receptive to the discharge plan if it comes from someone they trust. Be mindful of cultural or language barriers, and remember the patient’s right to make his or her own discharge decision, even if it’s a bad one.
Cosgrove noted that behavioral health patients have additional discharge challenges because of the lack of beds in behavioral health facilities. She offered these six tips for inpatient discharge planning, based on her experience with a daily cross-functional planning meeting:
With staffing shortages across healthcare not likely to ease anytime soon, it’s important to be proactive and intentional about discharge planning. This starts the moment patients arrive in the ER and goes through all conversations with families and the care team.
YouCompli sponsored MHA’s 2022 Healthcare Legal Compliance Forum. To access the full session recording, please contact the Massachusetts Health and Hospital Association.
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