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By: Stephanie Jackson  |  Type: Article  |  On: October 27, 2017

CMS’ Discharge Planning Proposed Rule and the IMPACT on Post-Acute Care Transitions

The IMPACT Act, which is still in the process of being implemented today, was an effort to standardize those assessments across all PAC providers, so that case managers and others would be able to compare apples to apples and make the best care decisions for their patients.

No one knows better than a case manager the importance of quality data to help facilitate a safe transition of care for our patients. Quality data includes accurate, relevant and current information about the patient AND the post-acute care entities. In September 2014, Congress passed the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. At the time, patient assessment data was standardized by provider type, but not across the different post-acute care (PAC) settings. So, a skilled nursing facility, a physical rehabilitation center, and other types of PAC facilities might have completely different sets of questions they asked during patient assessments, and different ways of recording that information. The IMPACT Act, which is still in the process of being implemented today, was an effort to standardize those assessments across all PAC providers, so that case managers and others would be able to compare apples to apples and make the best care decisions for their patients.

“In essence, the act seeks to standardize data elements used through various patient and resident assessment instruments by aligning certain data elements across instruments, to support our ability to measure and compare quality across the providers and settings of care,” said Patrick Conway, MD, MSc., CMS Acting Principal Deputy Administrator, and Deputy Administrator for Innovation and Quality, and CMS Chief Medical Officer, in a 2016 video from MLN Connects published on YouTube.1 “The act allows interoperability, which permits the seamless exchange of information across providers—not only PAC providers, but other providers who offer care to individuals as well. In the ideal state, important information would follow the patient, as services are delivered in hospitals and by physicians, long-term and PAC providers, and home- and community-based service providers. This will be a critical step towards coordinating care and proving Medicare beneficiary outcomes.” 

Certainly, the goals Conway mentioned are the same goals of case managers everywhere—to have a uniform way to measure and compare PAC providers in order to make the best possible decision for each patient based on his or her individual needs. But we’ve still got a ways to go.

In October 2015, just over a year after the introduction of the IMPACT act, CMS announced the Discharge Planning Proposed Rule, which would “revise the discharge planning requirements that hospitals, including long-term care hospitals and inpatient rehabilitation facilities, critical access hospitals, and home health agencies, must meet in order to participate in the Medicare and Medicaid programs,” according to CMS’ website.2 “The proposed changes would modernize the discharge planning requirements by: bringing them into closer alignment with current practice; helping to improve patient quality of care and outcomes; and reducing avoidable complications, adverse events, and readmissions.” Importantly, CMS says, the proposed rule would also, finally, “implement the discharge planning requirements” of the IMPACT Act.

Under the proposed rule, hospitals and critical access hospitals would be required to:

  • Develop a discharge plan within 24 hours of admission or registration;
  • Provide discharge instructions to patients who are discharged home (proposed for hospitals and critical access hospitals only);
  • Have a medication reconciliation process with the goal of improving patient safety by enhancing medication management (proposed for hospitals and critical access hospitals only);
  • For patients who are transferred to another facility, send specific medical information to the receiving facility; and
  • Establish a post-discharge follow-up process (proposed for hospitals and critical access hospitals only).

With already-heavy workloads, case managers are going to need sophisticated tools in order to be ready to meet these requirements when the rule takes full effect. For example, in order to develop a discharge plan within 24 hours as the proposed changes require, case managers will need to find a way to sift through information about hundreds of different PAC providers quickly and efficiently. Luckily, software solutions exist now that allow case managers and other hospital workers to do just that—a comprehensive database with contact and geographical information, quality scores, medical and non-medical resources, and corresponding financial information for a variety of PAC providers.

Another critical feature of such a database, when it comes to meeting the requirements of the new CMS proposed rule, is that both the clinical care team and the patient and family members can access the database to make sense of the choices available. That’s because the new rule has a lot more focus on taking into account the patient’s input in their own care. “The proposed rule emphasizes the importance of the patient’s goals and preferences during the discharge planning process. These improvements should better prepare patients and their caregivers to be active partners for their anticipated health and community support needs upon discharge from the hospital or post-acute care setting,” says the CMS website. “In addition, patients and their caregivers would be better prepared to select a high-quality post-acute care provider, since hospitals, critical access hospitals, and home health agencies would be required to use and share data, including data on quality and resource use measures. This results in the meaningful involvement of patients and their caregivers in the discharge planning process.”

Case managers are committed to providing the highest quality and most complete post-acute care information to our patients. We realize the importance of patient and family buy-in of the discharge plan and its direct impact on keeping the patients from being readmitted to the hospital, and I believe that most of my colleagues support the proposed rulings in the IMPACT Act to help make this a reality. We also know, however, that it’s really difficult to access current, clean PAC data (that we trust) in an efficient manner. We need a resource database that not only provides lists, qualifications and special offerings of post-acute care providers but offers quality scores to help assure the case manager is creating the best discharge plan. We have a ways to go, but I’m confident that this type of solution will blaze a new trail for our patients and care team members.

About Carelike

Carelike's extensive database of medical and non-medical transition care providers allows your discharge team to improve their efficiencies. Provider data is augmented with proprietary professional quality metrics as well as CMS scoring. Our technology provides ease of use standalone portals or EHR integration to help discharge teams select the best care providers. 

Organize your patient and family communication with our CareTrait technology. Comply with CMS initiatives including the proposed patient discharge IMPACT Act rule and significantly reduce the burden on this already over-stretched group of professionals. The solution greatly improves communication between discharge teams, patients and families and prioritizes preferred community-based services enabling the case manager to fulfill their responsibilities while improving care coordination. 






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By: Stephanie Jackson  |  Type: Article  |  On: May 08, 2017

Leveraging CMS reimbursements for post-acute and chronic patients

With proper billing-code utilization and the right care-coordination technology to match the best providers with care seekers, physicians and health care organizations involved in the discharge planning and care coordination of chronic and post-acute patients can be reimbursed for these services.

Since 2015, the Centers for Medicare & Medicaid Services (CMS) has been reimbursing doctors and health care organizations for providing chronic care management. Unfortunately, many organizations are not receiving this reimbursement and may be missing out on federal funding for some of the sickest Medicare beneficiaries. With proper billing-code utilization and the right care-coordination technology to match the best providers with care seekers, physicians, and health care organizations involved in the discharge planning and care coordination of chronic and post-acute patients can be reimbursed for these services. 

What are the CMS reimbursements?

As reported by ModernHealthCare, CMS made payments for chronic-care claims for just 513,000 Medicare beneficiaries of the approximately 35 million individuals eligible for this program. (To be eligible, individuals must have two or more chronic conditions.) Some of this gap stems from physicians' overall lack of awareness of the billing code for care management. However, by speaking with physicians, coordinating chronic-care services and using the right care-management billing codes, CMS will reimburse physicians and health care organizations for their time. 

The source noted that approximately 70 percent of Medicare beneficiaries have two or more chronic conditions. Examples of the covered conditions include, but are not limited to:

  • Alzheimer's disease and related dementia.
  • Arthritis (osteoarthritis and rheumatoid).
  • Asthma.
  • Diabetes.
  • Hypertension.
  • Depression.
  • Cancer.

Hospitals that partner with acute care nurses, discharge planners and care coordinators can take advantage of the average $42 per patient per month reimbursement for chronic-care service coordination and specialist consultations.

As noted in ModernHealthCare, another reason some health care providers are not taking advantage of this opportunity is due to the necessary written patient permission for the reimbursements. However, the 2017 add-on now eliminates the need for written consent and allows a verbal okay from patients.

According to CMS, the payable CCM service codes include:

  • CPT code 99490: covers 20 minutes of clinical staff time once a month for patients with two or more chronic conditions at significant risk of death or functional decline. The chronic care management services are required to have established, implemented, revised or monitored a comprehensive care plan.
  • CPT code 99487: covers 60 minutes per month of clinical staff time for complex chronic care involving moderate or high complexity medical decision making.
  • CPT code 99489: covers additional 30-minute block for qualified clinical staff time, once per month.
  • HCPCS code G0506: an add-on, covers qualified clinical staff time for the initiating visit with a patient to develop a comprehensive assessment and care plan.

Some of the services included under the CCM cover:

  • Continuity of care with designated care team members.
  • Comprehensive care management planning.
  • Transitional care management.
  • Coordination with home- and community-based clinical service providers.

Qualified clinical staff include:

  • Physicians.
  • Certified nurse midwives.
  • Clinical nurse specialists.
  • Nurse practitioners.
  • Physician assistants.

CMS also noted that CCM services are priced in both facility and non-facility settings, including skilled nursing, nursing, assisted living or other facility settings.

Reducing patient hospital readmittance

Patient readmittance in the first 30 days results in a CMS reimbursement penalty, so it's imperative that discharge nurses have top quality care providers for post-acute and chronic patients.

Unfortunately, research studies showed that 17.3 percent of Medicare fee-for-service patients aged 65 and over were readmitted within 30 days in 2012, according to the National Health Statistics Report. Readmissions occurred due to care coordinators poorly managing transitions during discharge, infections or complications caused by the hospital stay or the reappearance of the condition that led to the hospitalization in the first place.

Reducing readmissions falls on care coordinators in charge of locating care providers with the skills and qualifications that best suit the needs of the patient.

To accomplish this, care coordination companies, such as hospitals or health IT companies, are building discharge-planning software. However, these platforms need a robust database of talented and experienced care providers to ensure post-acute and chronic patients recover quickly and do not need readmittance.


Care coordinators need to reduce the hospital readmission rate of chronic patients.

Care coordinators need to reduce the hospital readmission rate of chronic patients.

Follow-up calls between visits to primary care physicians

One way to help reduce the chances for chronic and acute patient readmission is to provide ongoing treatment and care following a hospital discharge. This enables an open dialogue and regular visits to ensure the patient is following the physician's recommendations. 

Individuals receiving ongoing treatments from their primary care physicians and suffering from two chronic conditions need extra care providers in between doctor visits. Aligning these care services along with the CMS reimbursement is important to capture lost revenue opportunities.

How Carelike can help

Sometimes the biggest obstacle to taking advantage of the CMS reimbursement is finding the best-suited care providers to deliver post-discharge and follow-up services. Matching a nurse without the right qualifications can lead to readmission, which penalizes the reimbursement. Often, as noted by the Center for Healthcare Quality & Payment Reform, the inability to receive good primary care support in the local community is a main contributor to preventable readmissions.

Care coordinators arranging for discharge planning or long-term follow-up services for chronic patients need easy access to a wide range of care providers. Further they need the ability to accurately tailor their searches to locate the most appropriate health care professional to align with unique care seeker needs. By identifying the best local care providers for managing post-discharge chronic care patients, hospitals can reduce their readmission rates and ensure they're receiving the full CMS reimbursement.

Carelike creates a custom portal for care coordinators, who can then use licensed data that focuses on either national or local/regional care providers. Hospitals that already have their own systems can rely on Carelike's API that simply plugs into existing systems for easy access to the extensive database.

Using Carelike's dashboard, care coordinators can easily track patient statuses, add noted, document care transitions and take advantage of the extensive database of providers who all manage chronic and post-acute conditions. This provides an additional layer of context during the transition phase that's crucial for communicating additional information about patients.

Companies in the process of building a software solution to meet the growing need of matching care providers with care seekers could benefit from using the Carelike database.

Carelike provides the technology and resources to help hospitals, health care organizations and care coordinators take advantage of CMS reimbursements for chronic care and post-acute care management. Click here to learn more about Carelike.

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By: Stephanie Jackson  |  Type: Article  |  On: November 16, 2016

Uber used as transportation for home health providers

The terms "Uber" and "healthcare" have been used together a lot in the news lately, and it's no wonder.

Ride-sharing apps like Uber have taken over a considerable share of the transportation market in the past several years, especially in cities. Though the benefits of grabbing a ride from your phone are obvious for the general public, many businesses in the private sector are beginning to capitalize on the affordability and ease of use with Uber, including the healthcare sector.

Paving the way
Circulation, a transportation platform based in Boston, is now setting up a platform with health systems to arrange rides with Uber's application programing interface. Many experts working within Circulation believe this model has huge potential, as it could provide a reliable form of transportation for home health workers. It also works on demand to deliver high-quality healthcare workers to patients suffering from non-emergency medical issues safely and accurately. According to Home Healthcare News, John Brownstein, Circulation's co-founder, Harvard Medical School professor and a health care adviser to Uber, Circulation is already looking toward the future.

"That would be the next phase of this platform," he said. Brownstein went on to explain that Circulation was "designed with seniors in mind … there's definitely an opportunity to use Circulation for on-demand home health services." 


Apps like Uber could become a useful tool in the home health industry soon.Apps like Uber could become a useful tool in the home health industry soon.

Working with hospitals and providers to use Uber for home healthcare could indeed help many seniors suffering from cognitive issues, such as dementia and Alzheimer's. These patients might feel more comfortable seeing a medical professional in their own homes. The same could be true for homebound seniors with physical impairments, such as those who rely on a cane or wheelchair to get to their appointments.

Is an 'Uber for healthcare' on the rise?
The terms "Uber" and "healthcare" have been used together a lot in the news lately, and it's no wonder. After all, on-demand services are incredibly easy to use and convenient, which is not the case for healthcare in many ways. Wait times to see a healthcare professional are rising, and many people want the personal connection with providers that quick appointments don't always allow. It would seem that an "Uber for healthcare" would solve many of these issues.

Still, there are some professionals in health tech who are wary about on-demand health services. In a recent TechCrunch article, the argument is that healthcare is a multi-faceted need for consumers and can't be solved in the one-time transaction, such as a ride to the airport. Most people, the author argues, value the doctor-patient relationship above anything else, which can be hard to nail down in an on-demand experience.

However, that's not to say that Uber can't be a great stand-alone tool for health systems to use for homebound seniors or patients with cognitive decline. Brownstein also spoke with the Boston Globe about a project he led last year called UberHEALTH, which successfully helped transport medical professionals in Boston and 35 other cities to administer more than 2,000 flu shots. In a survey given to those who participated in the program, 78 percent said that the delivery of the vaccine was crucial in deciding to be part of the platform.

While it's still unclear whether or not Uber will turn into a fixed part of the healthcare system, there are signs that it could become more common in the home health sector in the future. 

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