The blog post was authored by Leslie Fried, senior director of the National Council on Aging Center for Benefits Access, and Anne Montgomery, a senior policy analyst for Altarum Institute, a nonprofit health systems research and consulting organization.
The authors argue the services provided by many community organizations — including home and physical environment modifications, access to assistive technologies, transportation, meals, household services and housing support — are essential to millions of Medicare beneficiaries.
“Absent clear requirements for healthcare providers to coordinate with social services organizations, risks will remain high that many fragile, complex older adults living in the community will fall through the cracks and into crisis, cycling in and out of high-cost healthcare settings,” according to Ms. Fried and Ms. Montgomery.
To avoid letting these patients go ignored, programs that focus on optimizing coordination of medical care and community services, as well as programs that enhance discharge planning, will become even more crucial.
Highlighted below are six ways the blog authors suggest the industry improve in those areas.
1. Boost funds for community social services organizations. CMS should direct nonprofit hospitals to analyze service shortages as part of their community needs assessments and for-profit hospitals to work with public health officials to identify service inadequacies.
2. Encourage discharge planning process assessments. Similar to community needs assessments, CMS could have hospitals create advisory committees to conduct periodic reviews of their discharge planning and patient outcomes.
3. Create a list of core elements as a basis for a common care plan. A list of core elements would simplify care coordination and streamline communication between providers, making it less confusing for families taking an ill or disabled loved one home.
4. Engage family caregivers in the conversation. Although the CMS-proposed regulations acknowledge the importance of caregivers, there is no requirement for hospitals to engage them in the discharge planning process. The federal agency could require hospitals to document that a family caregiver has been contacted about providing discharge support.
5. Improve medication reconciliation and health IT. CMS should encourage hospitals to use pharmacists or physicians to track patient medication problems, when possible. The agency can implement a required standard format for recording medication and care plans in patient records.
6. Makes discharge planning documents more accessible. Currently, protocols governing medical records make it hard for family caregivers to access these documents until after a patient is discharged, even with the patient’s signed consent. Although patient privacy is importance, these protocols “should not be allowed to be extended to discharge planning documents,” according to the authors.
“CMS’ discharge planning regulation is moving in the right direction,” concluded the blog authors. “As the agency considers these and other ideas for improvement, we hope that the agency will take the opportunity to advance a national conversation on how discharge planning can play a key role in health and social services delivery system reforms.”
