Hospital Transitions: A Guide for Professionals · Discharge planning evaluation must identify Patient’s ability for self-care If there are caregivers who can be trained to provide

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Hospital Transitions:

A Guide for Professionals

2017

Medicare Rights Center

The Medicare Rights Center is a national,

nonprofit consumer service organization that

works to ensure access to affordable health

care for older adults and people with

disabilities through

Counseling and advocacy

Educational programs

Public policy initiatives

Page 2© 2017 Medicare Rights Center

National Council on Aging

This toolkit for State Health Insurance

Assistance Programs (SHIPs), Area Agencies

on Aging (AAAs), and Aging and Disability

Resource Centers (ADRCs) was made

possible by grant funding from the National

Council on Aging


Learning objectives

Understand Medicare Part A’s coverage of hospital

stays

Explain a beneficiary’s right to discharge planning

Know how Medicare covers post-hospital skilled

nursing facility (SNF), home health, and hospice care

Identify a beneficiary’s options for long-term care

following a hospital stay


Medicare basics

© 2017 Medicare Rights Center Page 5

Health insurance for people age 65+ and many of

those who have received Social Security disability

benefits for 24 months

People of all income levels are eligible

Run by the federal government but can be provided

by private insurance companies that contract with the

federal government

What is Medicare?


Medicare eligibility: Age

Individual 65+ is eligible for Medicare if one of the

following conditions is met:

1. They either receive or qualify for Social Security retirement

cash benefits

OR

2. They currently reside in the United States and are either

A U.S. citizen or

A permanent U.S. resident who has lived in the U.S. continuously

for five years prior to applying


Medicare eligibility: Disability

Individuals under 65 are eligible for Medicare if they have

been receiving Social Security Disability Insurance (SSDI)

for 24 months

Individuals are Medicare-eligible the first day of the 25th month of

receiving SSDI

Exception: Those who receive SSDI because they have ALS

become eligible the first month their SSDI benefits start


Medicare eligibility: ESRD

Individuals are also eligible for Medicare if they have End-

Stage Renal Disease (ESRD)

Get dialysis treatments or have had a kidney transplant

Have applied for Medicare benefits

Have been deemed eligible for SSDI, railroad retirement benefits,

or are otherwise considered to be fully insured by Social Security


Medicare options: Original Medicare

Original Medicare

Made up of three parts

Part A – hospital insurance/inpatient insurance

Administered by the federal government

Part B – medical insurance/outpatient insurance

Administered by the federal government

Part D – prescription drug benefit

Provided by private insurance companies


Medicare options: Medicare Advantage

Medicare Advantage

Also known as Part C

Provided by private insurance companies that

contract with federal government to provide

Medicare benefits

Combines Part A, Part B, and usually Part D benefits

in the same plan

Not a separate benefit


Part A hospital care

coverage


Hospital coverage

If beneficiary is hospital inpatient, Part A covers

Semi-private room

Meals

General nursing

Medications

Other hospital services and supplies

Part A does not cover

Private duty nursing

Private room, unless medically necessary

Personal items (razors, socks)


Part A costs


Medicare Part A Costs for 2017

Premium Free for those with 10 years of Social Security

work history

$227 if beneficiary or spouse worked and paid

Medicare taxes for 7.5 to 10 years

$413 if beneficiary or spouse worked and paid

Medicare taxes for fewer than 7.5 years

Hospital deductible $1,316 for each benefit period

Hospital coinsurance $329 per day for days 61-90 each benefit period

$658 per day for days 91-150 (these are 60 non-

renewable lifetime reserve days)

Skilled nursing facility

(SNF) coinsurance

$164.50 per day for days 21-100 each benefit

period

Hospital discharge

planning


Hospital discharge planning

A beneficiary has the right to discharge

planning at the end of their hospital stay

Process to determine most appropriate post-hospital

discharge destination and care plan for patient

Key component of preventing hospital re-admissions

Medicare expects providers to have basic

knowledge of discharge planning requirements

When to screen a patient to determine if they need a

discharge plan

How to evaluate an individual and develop the

discharge plan


Who qualifies for discharge planning?

Hospital inpatients

Medicare requirements:

Hospital screens inpatient to identify those who would be

at risk for complications without a discharge plan

Hospital provides detailed discharge plan if

Screening determines inpatient is at risk for complications

Inpatient’s physician requests discharge plan

Inpatient or caregiver requests screening, and screening finds

discharge plan is needed

Medicare recommendations:

Hospital provides detailed discharge planning to all

Medicare inpatients


Who qualifies for discharge planning?

Hospital outpatients

Medicare requirements:

Hospitals are not required to provide discharge planning to

outpatients

Medicare recommendations:

Hospital provides discharge planning to outpatients

Can be shortened discharge plan

Especially those who are discharged from observation

stays, same-day surgery, or the emergency department


Discharge planning steps


Hospital should start screening patient for the

need for a discharge plan when patient is formally

admitted, or as soon as possible

Hospital staff share discharge plan with patient

and/or caregiver(s)

Discharge plan is implemented

If hospital determines patient needs a discharge

plan, appropriate hospital staff conduct an

evaluation of patient and create plan

Discharge plan screening

Hospital should screen patient when they are

admitted to determine if they will need a

discharge plan

For more complicated cases that may delay

screening, Medicare recommends that

screening occur within 48 hours before patient

is discharged

If patient’s condition worsens after first

screening, they should be screened again


Who creates the discharge plan?

Must be developed or supervised by registered

nurse, social worker, or other qualified hospital

staff

If not nurse or social worker, discharge planner

must have

Previous discharge planning experience

Knowledge of the social and physical factors that

affect a patient’s functional status at discharge

Knowledge of community services and resources


Discharge planning evaluation

Patients whose screening reveals a need for

discharge plan receive formal evaluation

Hospital should consider

Patient’s functional status and cognitive ability

Type of post-hospital care that patient needs

Availability of required post-hospital health care

services

Availability and capability of family and/or friends to

provide follow-up care in the home


Discharge planning evaluation (continued)

Evaluation includes assessment of

Patient’s physical, psychological, and social needs

Patient’s goals and preferences as explained directly

by patient or caregiver

Whether it is realistic for patient to return to their pre-

hospital environment (home or facility)

Hospital must be familiar with abilities and

capacity of local service providers so they can

create realistic discharge plans that meet

patient needs


Patients returning home

Discharge planning evaluation must identify

Patient’s ability for self-care

If there are caregivers who can be trained to provide

care

Patient’s need for further health care services

For example: Follow-up appointments, home health

care, physical or occupational therapy, hospice, dialysis,

durable medical equipment (DME)

Available supportive social services

Patient’s need for home modifications,

housekeeping, and/or meal services


Patients returning to facility

Discharge planning evaluation must identify Whether the patient has a preferred facility

Whether facility has capacity for patient after hospital stay

Patient’s access to insurance coverage for post-hospital care

Hospital staff should know Medicare and Medicaid

requirements for post-hospital care coverage

Should inform patient if they will have to pay out of pocket

Providers must give patients list of available Medicare-

participating skilled nursing facilities (SNFs) that serve the

geographic area the patient requests

Medicare recommends that hospitals form partnerships

with post-hospital care providers

For example: Centers for Independent Living (CILs), aging and

disability resource centers (ADRCs)


Discharge plan implementation

Hospital staff shares discharge plan with patient and/or caregiver

Medicare requires hospital to arrange for initial implementation

Patients returning home must receive Easily readable discharge plan

Checklists

Plain, culturally sensitive language free from jargon or acronyms

Legible and complete medication list with drug dosage and administration

In-hospital training and education for patient and/or caregiver

Teach-back approach: Patient and caregiver explain instructions back to provider to ensure understanding


Discharge plan implementation (continued)

Hospitals at a minimum must arrange, if

needed, the following:

Transfer to post-hospital facility that accepts

Medicare or is in-network

Referrals to nearby home health agencies or hospice

providers that accept Medicare or are in-network

Referrals to follow-up appointments and DME

suppliers

Referrals to community resources


Documentation requirements

Hospital inpatient’s file should contain the

following

Discharge planning evaluation

Summary of patient’s stay

For example: Treatments, symptoms, pain management,

whether patient was in seclusion or physically restrained

Documentation of conversation about discharge plan

that hospital staff member had with the

patient/caregiver

Copy of the discharge plan


Appealing hospital discharge

Beneficiaries can appeal if they think the hospital is making

them leave too soon• Steps to ask for a review are listed on the Important Message from

Medicare notice • Beneficiary should receive the notice within two days of entering the hospital

as an inpatient

• A hospital discharge appeal goes to the Quality Improvement

Organization (QIO), an independent body that decides on inpatient

discharge appeals

Patients should pay close attention to the deadline for requesting an

appeal

Most QIO decisions are expedited, and the QIO must tell the

beneficiary its decision by close of business the day after the

appeal is made If appeal is filed on time, hospital cannot charge patient until QIO

makes its decision

Further levels of review are available


Post-hospital care


Types of post-hospital care

Medicare coverage includes

Outpatient therapy services (Part B)

Skilled nursing facility (SNF) care, including skilled

nursing and therapy care (Part A)

Home health care (Parts A and B)

Hospice care (Part A)

Medicare does not cover long-term care

Patients requiring long-term care likely need to get

coverage from other sources, such as Medicaid


Part B outpatient therapy coverage

Part B covers

Outpatient physical, occupational, and/or speech therapy

Part B covers if

Patient needs therapy, and their doctor considers it a safe

and effective treatment

Patient needs technical skills that trained therapist can provide

or oversee

Doctor or therapist sets up plan of treatment before care

begins

Therapist performs services or directs staff who perform

services

Doctor or therapist regularly reviews plan of treatment to

see if changes are needed


Part A SNF coverage

Part A covers Semi-private room and meals

Skilled nursing and/or therapy (see next slide)

Medically necessary medications

Medical supplies and DME

Medical social services

Ambulance transportation, when necessary

Part A covers these if patient Has been hospital inpatient for 3 consecutive days prior to SNF

stay

Enters Medicare-certified SNF within 30 days of leaving

hospital

Needs skilled nursing care 7 days/week or therapy at least 5

days/week


Skilled nursing care

Care that needs to be performed by a registered nurse

(RN) or licensed practical nurse (LPN)

Services may include:

Intravenous injections

Tube feeding

Catheter changes

Changing sterile dressings on a wound

Training patient and caregiver to perform required tasks

Observation and assessment of individual’s condition if they

may have complications or their health may worsen

Management and evaluation of plan of care


Skilled therapy services

Unlike outpatient therapy, covered by Part A

Services that can only be performed safely and

correctly by a licensed therapist and that are

reasonable and necessary for treating an illness or

injury

Services include

Physical therapy

Speech-language pathology

Occupational therapy


Parts A and B home health care coverage


Parts A and B cover Intermittent skilled nursing care

Physical and speech therapy

DME and medical supplies

Medical social services

Home health aide services (personal care), in certain cases

Occupational therapy, if skilled care or other therapies needed

Parts A and B cover these if patient Is homebound

Needs skilled nursing services and/or therapy

Has a face-to-face meeting with a health care professional within 90 days of getting home care or 30 days after getting care

Has a doctor certify a plan of home health care every 60 days

Receives care from a Medicare-certified home health agency

Homebound requirement

Homebound typically means patient needs help to

leave the home, e.g., crutches, a walker, a

wheelchair, another person

Whether or not someone qualifies as homebound is

decided by a doctor’s evaluation of their condition

over an extended period of time, not on a daily or

weekly basis

Leaving home for medical treatment and attending a

licensed or accredited adult day care or religious

service is always permitted


Excluded home health care services

Medicare’s home health care benefit does not cover:

24-hour-per-day care at home

most prescription drugs (these are covered by Part D)

meals delivered to someone’s home

prosthetic devices not used under a plan of care

care from a respiratory therapist

personal care by itself

Personal care is only covered if individual also needs skilled nursing or therapy care

housekeeping by itself

Housekeeping services are covered if provided during a covered home health aide visit to provide personal care

If the beneficiary is terminally ill, the Medicare hospice benefit may pay for some of these services


Coverage of maintenance services

Medicare covers SNF, home health, and outpatient therapy

care regardless of whether the patient’s condition is temporary

or chronic, or whether or not the individual is improving

Restoration potential is not needed for a service to be covered

The improvement standard cannot be applied when Medicare is

determining coverage of claims that require skilled care

Although beneficiaries often hear otherwise, Medicare covers

services intended to help patients maintain their ability to

function or to prevent or slow worsening

A class action lawsuit against the Department of Health and

Human Services was settled in 2013, ensuring that the

improvement standard cannot be applied by Medicare or plans

Applies across the country


Part A hospice care coverage


Part A covers Doctor services and nursing care

Therapy

Short-term inpatient care

Short-term respite care for caregiver

Hospice aide and homemaker services

Drugs for pain management and/or symptom control

Grief and loss counseling

Part A covers these if patient Is certified by a doctor as terminally ill (i.e. a life expectancy of

six months or less)

Signs a statement electing hospice care instead of curative

care

Receives care from a Medicare-certified hospice agency

Can take place in hospital, nursing home, beneficiary’s home,

other health care settings

Medicare and long-term care

Medicare does not cover most long-term care,

such as

24-hour-per-day care

Meal delivery

Help with activities of daily living, if that is the only

care a patient needs

Care in an assisted living facility or nursing home

Individuals who have chronic illness or disability

and need extensive long-term support services

may need insurance other than Medicare to

cover those services


Long-term care options

Medicaid All state Medicaid programs cover nursing home care and home care

Income and asset limits

Contact local Medicaid office to learn more

Program of All-Inclusive Care for the Elderly (PACE) and certain managed care demonstration projects (state-specific) Government program available in some states to individuals with

Medicare and Medicaid who meet other state standards

Contact local Medicaid office to learn more

Long-term care insurance Provided by private insurance companies

Generally covers nursing home care and home care

Veterans’ Affairs (VA) benefits Provides long-term care services to some eligible veterans

Contact local VA facility to learn more


For more information and help

Local State Health Insurance

Assistance Program (SHIP)

www.shiptacenter.org

www.eldercare.gov

Social Security Administration

1-800-772-1213

www.ssa.gov

Medicare

1-800-MEDICARE (633-4227)

www.medicare.gov

Medicare Rights Center

1-800-333-4114

www.medicareinteractive.org

National Council on Aging

www.ncoa.org

www.centerforbenefits.org

www.mymedicarematters.org

www.benefitscheckup.org


http://www.shiptacenter.org/

http://www.eldercare.gov/

http://www.ssa.gov/

http://www.medicare.gov/

http://www.medicareinteractive.org/

http://www.ncoa.org/

http://www.centerforbenefits.org/

http://www.mymedicarematters.org/

http://www.benefitscheckup.org

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Web-based compendium developed by Medicare Rights for use as a look-up guide and counseling tool to help people with Medicare Easy to navigate

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(HMO, PPO or PFFS) and Original Medicare?”

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For details, visit www.medicareinteractive.org/learning-

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Documents

Hospital Transitions: A Guide for Professionals · Discharge planning evaluation must identify Patient’s ability for self-care If there are caregivers who can be trained to provide