Long-Term Care

Discharge Planning Under the MDS 3.0

LTC Educator's Corner, March 1, 2010

As federal attention to preventable rehospitalizations increases, SNFs should ensure that their discharge planning processes include steps to provide residents with the equipment, education, and access to services they need to remain safe and healthy in the home environment.

“One of the biggest mistakes facilities make with discharge planning is that they do not make sure a resident and his or her home is adequately prepared prior to discharge,” says Frosini Rubertino, RN, CRNAC, C-NE, CDONA/LTC, HCPro Boot Camp instructor and clinical services consultant at LTC Systems, a long-term care clinical consulting firm in Conway, AR. “If the home is not prepared to meet the resident’s needs, the risk of rehospitalization can increase.”

The SNF’s responsibility to ensure that residents are safe and receive the necessary care does not stop at the facility doors. “Facilities should review their discharge planning process and make sure it is started  early, involves the resident and/or family, and provides the resident with the education, community contacts, equipment, and other information he or she needs to remain independent in the home for as long as possible,” Rubertino says.

The discharge planning process
Including the resident and his or her significant family members in the MDS process is crucial for discharge planning because their expectations about the ultimate goals and outcomes will help the interdisciplinary team develop a care plan specific to the resident’s needs.  

“It’s similar to building a house; before you go to the builder, you already have an idea of what you want the house to look like. You have a blueprint. You don’t just tell the builder to build you a house without showing him the blueprint,” Rubertino says. “If the resident and family members expect the resident to eventually return home, you can develop your care plan with that ultimate goal in mind. You have to focus on the outcome.”

Prior to discharge, the interdisciplinary team is responsible for providing the resident with a discharge summary and the post-discharge plan of care. The discharge summary should include a variety of information, such as the functional status of the resident upon admission, his or her progress, and his or her needs once the resident is back in the community setting or the next level of care. 

“Every resident should receive a discharge summary, regardless of where they are being discharged to,” says Maureen McCarthy, president of Celtic Consulting in Goshen, CT. “The MDS coordinator, unit manager, member of the social service department, dietitian, therapist, and physician should be involved in developing the discharge summary.”

The post-discharge plan of care is similar to the discharge summary in terms of what the resident will need after being discharged from the SNF, but the post-discharge plan of care typically addresses these issues in more detail.

 “Although some people think that the next level of care or home care provider should develop the post-discharge plan of care, I think this should be done prior to discharge from the SNF so there is enough time to make arrangements for the home care setting or other facility the resident is being discharged to,” Rubertino says. “The post-discharge care plan should address specific safety issues, assistive devices, equipment, and other items or services the resident will need.”

Facilities are also responsible for providing education to the resident regarding proper self-care. This education is usually provided throughout the resident’s SNF stay, but if not, it must occur prior to discharge.

Beyond the basics
Although the discharge summary, post-discharge plan of care, and self-care training are essential components to the discharge planning process, merely providing the resident with this information is not enough.

 “Don’t just give them information, discuss it. Discuss the resident’s needs, requirements for the home, and service options with the resident and his or her family members,” Rubertino says. “They may not be aware of all the resources and services in the community, so you should walk them through what is available rather than just giving them a list.”

The key to a good discharge planning process and successful transitions between levels of care is to communicate with the resident and family members and check to make sure they have everything the resident needs prior to discharge.

“You really have to look at each discharge individually and make sure it is appropriate,” McCarthy says. “For example, if you have a resident that will be discharged on a Friday afternoon, there may not be a home health aide available on Saturday. So if the resident is going home, he or she may not have services during that first weekend. The interdisciplinary team must decide if the resident will be able to function without these services, and if not, the discharge should be delayed until Monday when the services would be available and it would be a better transition for the resident.” 

MDS 3.0 changes
SNFs should ensure that residents and their homes are adequately prepared prior to discharge not only because it could reduce the risk of rehospitalization, but also because the MDS 3.0 will draw attention to this aspect of discharge planning.

The MDS 3.0 contains two new items related to discharge planning: Q0500, Return to Community, and Q0600, Referral. These items are intended to support a resident’s expressed interest to return to the community and ensure collaboration between the SNF and the local contact agency to facilitate this transition.

“The way things are now, for short-term stays, discharge planning is usually pretty thorough and generally progresses as it should, ending with a discharge back to a noninstitutional setting. When discharge back to the community does not appear to be feasible on admission, though, the possibility for discharge often is not reevaluated through the stay, even though a resident’s situation might change over time,” says Rena R. Shephard, MHA, RN, RAC-MT, C-NE, president of RRS Healthcare Consulting Services in San Diego. “Discharge might become feasible, and the resident might want to explore the possibilities. That’s where section Q [of the MDS 3.0] comes in.” 

Certain answers to Section Q items will trigger the need for a discharge planning evaluation, which will be done by a local contact agency in collaboration with the facility. 

Shephard says the need for a discharge planning evaluation is triggered when:

  • The resident or family wants to speak to someone about return to the community (Q0500B = 1) and 
  • There is no discharge plan in place for the residentto return to the community (Q0400A = 0) and 
  • A determination was made that discharge to the community was feasible (Q0400B = 1) 

 (For information about how to code MDS 3.0 items Q0500 and Q0600, see “Coding the new Section Q items” on p. 4.)

In addition to the new items related to discharge planning, the MDS 3.0 will require facilities to complete a discharge assessment. This assessment must be completed within seven days of the Event Date (item A2000) and submitted within 14 days of the Event Date.

“When a resident is discharged by MDS definition, a discharge assessment is required [under the MDS 3.0] regardless of whether the discharge is return anticipated or return not anticipated,” Shephard says. “An assessment is not required with MDS 2.0, just a discharge tracking form with a few brief items on it.”

Although the discharge assessment required under the MDS 3.0 means more work for the interdisciplinary team, it could help improve care transitions and even the quality of care people receive. 

“I think the discharge assessment may be the beginning of a process that will someday be able to track an individual’s progress across healthcare settings,”  Shephard says.

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