Transitional Planning and
  Case Management

In these times of fixed payments, whether they are due to prospective payment or managed care reimbursement systems, healthcare organizations no longer can afford to keep patients at one level of care for an extended period of time. Without ongoing assessment for timely transfer to a more appropriate level of care, these organizations risk either no reimbursement for services rendered or denial of payments for all or a portion of these services. Transitional planning, traditionally known as discharge planning, is the process case managers apply daily, in conjunction with utilization management. It ensures that appropriate services are provided and that these services are provided in the most appropriate setting (i.e., level of care) as delineated in the standards and guidelines of regulatory and accreditation agencies (federal and private). This chapter focuses on the transitional planning process and its relationship to case management.
     
Transitional planning places the case manager in a pivotal position in the patient care delivery process, especially where decisions are made to ensure quality, safe, efficient, cost-effective, and continuous care and transitional plan. Transitional planning is defined as a dynamic, interactive, collaborative, and interdisciplinary process of assessment and evaluation of the healthcare needs of patients and their families or caregivers during or after a phase/episode of illness. Transitional planning also includes planning and brokering of necessary services identified based on the patient's condition. In addition, it ensures that these services are delivered in the patient's next level of care (i.e., setting) or after discharge from a hospital. This process is systematic and aims to facilitate the transition of patients from one level of care to another more appropriate, necessary, and reimbursable level without compromising the quality and continuity of care or the services being provided.
     
Transitional planning involves a team of healthcare providers from within the healthcare organization: the patient, family, case manager, and other relevant providers, such as the managed care case manager, physician, social worker, physical therapist, occupational therapist, speech pathologist/therapist, pharmacist, and financial screener/reviewer. This team may also include other representatives from agencies that are external to the organization, such as home care, skilled nursing facilities, hospice, and transportation. Not every member of this transitional planning team is involved to the same degree. Some members may only be involved based on their specialization and as they relate to the needs of patients. For example, a patient with cardiovascular disease would not routinely require the services of a speech pathologist/therapist, whereas a patient who has had a stroke would. The case manager usually ensures that the appropriate members of the healthcare team are involved in the transitional planning process as the condition of the patient warrants.

TRANSITIONAL PLANNING OR DISCHARGE PLANNING

Transitional planning was not born by happenstance. Over the years and as in any evolutionary process, some sociopolitical factors contributed to the advent of discharge planning and later to its evolution into transitional planning. Discharge planning was not a component of case management until the late 1980s, when healthcare organizations began to view unnecessary use, fragmentation, and duplication of resources as wasteful and cost-ineffective. In addition, certain pressures such as the prospective payment system in acute care settings forced hospitals to reduce the patients' length of stay, which was basically accomplished through discharging patients expeditiously. However, the shift to transitional planning did not occur until legislative changes in reimbursement and care delivery (i.e., the Omnibus Budget Reconciliation Act [OBRA] of 1986 and the Balanced Budget Act of 1997) took place, coupled with the increased incidence of managed care in the 1990s. Only then did transitional/discharge planning evolve to a necessary function of every acute care hospital and every case management program.
    
Rather than discharge planning, the term transitional planning better demonstrates the essence of this process and its intent. This can be substantiated in three ways. First, transitional planning describes the act of transitioning patients from one level of care into another within or outside the acute care organization (i.e., from intensive care to intermediate step-down, or regular floor, and then discharge), whereas discharge planning basically focuses on discharging patients from acute care settings to another facility or to home, discounting the different levels of care within the acute care setting. Second, transitional planning means the beginning of a new phase of care, whereas discharge planning denotes ending care. The use of the term discharge planning, then, is not truly reflective of case management because case management also includes the act of managing patients' transitions across the healthcare continuum and services instead of focusing on the care provided in a single setting or level of care. Third, transitional planning, as a terminology, reflects the way managed care reimbursement functions, that is, reimbursement based on the level of care provided and the transitioning of patients from one level to another, less complex level until the patient is ready for discharge from the service or the setting.

Driving Forces for Transitional Planning
Transitional planning as a function performed by case managers is important for several reasons, some of which follow.

Mandates of Regulatory Agencies and Professional Societies
Transitional planning has been mandated or advocated for by federal agencies in the form of legislation, by accreditation agencies in the form of accreditation or performance standards, and by professional organizations/associations in the form of policies or practice guidelines (Box 1). For example, OBRA mandates that hospitals have a transitional planning program in place to meet the Medicare's conditions of participation or to be eligible for providing services to Medicare patients (OBRA, 1986). The continuum of care standard of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) calls for hospitals to have explicit policies and procedures for discharge planning that ensure early identification of patients' needs for postdischarge services and to have a process in place for the coordination and arrangement of these needs. JCAHO also requires hospitals to establish a process for the assessment of available and appropriate resources for this purpose. This process entails gaining knowledge of the resources available for patients within the internal and external healthcare environments (JCAHO, 2001).
    
To assist in meeting the requirements of federal and accreditation agencies and to help hospitals develop solid discharge/transitional planning programs, the American Hospital Association (AHA) published its guidelines for discharge planning in 1984. These guidelines apply mainly to the acute care settings. They explain the essential elements of discharge planning: early identification of patients in need for postdischarge services, patient/family education, assessment and counseling, development of the discharge plan, coordination and implementation of the discharge plan, and follow-up after hospital discharge (AHA, 1984).
    
The American Nurses Association (ANA) in its Standards of Clinical Nursing Practice described the role and responsibilities of the nurse in discharge planning and continuity of care (ANA, 1991). According to these standards, the nurse is expected to collaborate and consult with other providers in the provision of safe and quality patient care. This entails the assessment of patients' needs, making referrals to other providers, identifying and securing appropriate services available to address patients' health-related needs, ensuring continuity of care, and educating patients and their families regarding health needs and condition.
    
The AHA guidelines and the ANA standards functioned as resources for healthcare organizations to use in the development, implementation, and enhancement of their discharge planning programs and processes. Today there are specific case management standards and guidelines available that explain the role and responsibilities of case managers in discharge/transitional planning. These are advocated for by the Case Management Society of America (CMSA) (Box 2). In addition, certifying bodies for case manager's certification, such as the Commission for Case Manager Certification (CCMC) and the American Nursing Credentialing Center, include transitional planning as a topic or dimension of the certification examination (Box 3). This makes it necessary for case managers to assume the role of transitional planner and be knowledgeable in this function.
    
With the advent of case management, healthcare organizations, particularly acute care hospitals, reexamined who is best to assume the role of the discharge planner. The traditional method of having either a social worker or a registered nurse (RN) designated solely to this function/aspect of patient care became no longer acceptable. The pressures for efficient, quality, and cost-effective care delivery processes influenced healthcare executives to design models of practice and patient care delivery that eliminated the problems of fragmentation and duplication of services, roles, and responsibilities. Case management programs and delivery models became most popular because of their focus on addressing these pressures through consolidation of departments such as utilization management; quality improvement and management; clinical care management; social services; and, most importantly, discharge planning. Hence this became the beginning of an integrated case manager's role. Today this role most commonly integrates transitional planning, clinical care management, and utilization management (Case Manager's Tip 1). Such integration has demonstrated the best cost, quality, and consumer-related outcomes.

THE CONTINUUM OF CARE

Before we explain the role of the case manager in transitional planning, it is important to review the continuum of care. A focus on the continuum of care is instrumental for success in transitional planning and case management. To simplify the discussion, we decided to divide the continuum of care into three types of services and settings: preacute, acute, and postacute care and services. These are distinct in terms of scope, type, and cost of services (Table 1). The services provided in each of these settings are highly regulated and warrant that case managers be knowledgeable of the clinical, reimbursement, and eligibility guidelines for the provision of services in each setting. In addition, they must apply these guidelines when they collaborate with the members of the healthcare team in the development of the transitional plans for their patients (Case Manager's Tip 2). Moreover, case managers must be able to match the patient's condition to the appropriate next level of care with adequate consideration of the patient's health insurance plan and its related benefits (Case Manager's Tip 3 and Case Manager's Tip 4). Case managers are responsible for matching patients to the next appropriate level of care, which in most instances requires either the discharge or the transfer of a patient to another institution or care site. Table 2, Table 3, and Table 4 provide examples of the types of patients and services that are cared for in the different preacute, acute, and postacute settings, respectively. As case managers assess the conditions of their patients to make decisions pertaining to transitional planning, they apply the criteria of admission and discharge to and from the various care settings. In the case of Medicare- and Medicaid-participating organizations, these criteria are usually driven by federal reimbursement regulations (i.e., InterQual guidelines). For example, to transition a patient into an acute rehabilitation facility, the patient must be able to tolerate and participate in therapy for a minimum of 3 hours per day.
    
Case managers also apply the criteria used by managed care agencies (i.e., Milliman & Robertson) when indicated by the patients' insurance or health plans. In a practical or operational sense the InterQual and Milliman & Robertson criteria are usually referred to as either of the following:
  1. Intermediate outcomes; that is, outcome indicators when met by the patient's condition indicate the need to transition the patient to the next level of care. For example, a cardiology patient in an intensive care setting is transferred to the telemetry unit when the patient's condition no longer requires invasive hemodynamic monitoring.
  2. Discharge criteria; that is, outcome indicators when met by the patient's condition indicate the discharge of the patient completely from the healthcare organization/setting. Usually these criteria are applied for discharging a patient from a hospital/acute care setting. For example, a pediatric patient admitted for acute exacerbation of asthma is discharged home when he or she is breathing comfortably and shows adequate oxygenation or improvement in peak expiratory flow.
 The JCAHO has greatly influenced the healthcare organizations' view of and focus on the continuum of care and services in its accreditation standards. According to the JCAHO (2001), case management services must aim at coordinating care and services across the continuum of care. This is necessary especially because patients may need to receive a range of services in multiple settings and from multiple healthcare providers. This makes it essential for hospitals to view the care they provide to patients as part of an integrated system of settings, services, healthcare providers, and care levels. These characteristics make up the continuum of care. Therefore it is in the best interest of hospitals to ensure that they have a process in place that addresses compliance with the continuum of care standard described by the JCAHO. This process is the transitional planning process and must be applied for all patients and at every encounter. It is best ensured if case managers assume the responsibility for transitional planning, especially because they are better prepared for this function compared with other providers (Case Manager's Tip 5).
    
The JCAHO defines the continuum of care, focusing on the role acute care organizations (i.e., hospitals) play in transitional planning. Case management programs and delivery models enhance compliance with the continuum of care standard because of their natural focus on the care coordination activities JCAHO delineates in this standard in terms of the process of patients' admission and discharge from a hospital (Box 4). Not surprisingly, these activities are essential components of the transitional planning process.
    
In addition to the care coordination activities, JCAHO identifies six standards with which hospitals must maintain compliance to meet the requirements of the continuum of care function. These standards are as follows:
  1. The hospital must have a process in place to ensure that patients access the appropriate level of care and services they require based on their assessed needs.
  2. The hospital must accept patients to an appropriate level of care and services based on a completed assessment of needs. This assessment must be completed based on predefined criteria with regard to the patient information necessary to make appropriate decisions regarding the level of care, service, and setting.
  3. The hospital must have a process in place to ensure continuity and coordination of care and services over time.
  4. The hospital assesses the patient's needs and readiness for discharge, referral, or transfer to another level of care, setting, or provider. Such a decision must be made based on the hospital's and other facility's ability to meet the patient's needs. The hospital is obligated to inform the patient in a timely manner of the plan of discharge or transfer.
  5. The hospital must exchange appropriate and necessary information with other facilities and providers when transferring patients. This information is usually related to the services required for a patient's care.
  6. The hospital must have a clearly defined procedure for resolving denial of care conflicts. Such procedure must take into account the needs of patients as they are (re)assessed on an ongoing basis.
 These standards are relevant to case management and transitional planning. It is natural then to design a case manager's role that incorporates these functions. For example, standards 1 and 2 can be incorporated in the screening and case identification function of case managers, standard 2 can be addressed in the planning care function, standard 3 relates to the care coordination and facilitation function, standards 4 and 5 are appropriate components of the discharge/transitional planning function, and standard 6 can be incorporated in the utilization management function.
    
The Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA), is the federal agency that defines the standards of discharge planning in the form of Medicare's Conditions of Participation. These standards are available online in the State Operations Manual, Interpretive Guidelines for Hospitals, Tag Numbers A330 through A344, Medicare Conditions of Participation ยง482.43 (HCFA, 2001). Similar to the JCAHO's continuum of care standard, they focus on the process of transitional planning. A summary of these standards follows. More detailed information is available in Table 5. According to these regulations, hospitals are expected to do the following: It is evident in these regulations that hospitals must focus on the continuum of care in the provision of healthcare services. Similar to the JCAHO's standards, each of these requirements can be fit in one or more step of the transitional/discharge planning process. Therefore case management models and programs in acute care and other settings enhance compliance with Medicare's Conditions of Participation and JCAHO's standards of accreditation. Moreover, case managers, who are licensed professionals as stipulated in the regulations, are best suited to assume the responsibility for these functions. They can apply the transitional planning process for this purpose.

THE CASE MANAGER'S ROLE IN TRANSITIONAL PLANNING

Case managers are responsible and accountable for transitional planning in virtually every institution that employs case management delivery services. This section discusses the role of the case manager in transitional planning through the application of a systematic process (Figure 1) especially designed for that purpose. The goals of the transitional planning process are, but are not limited to, the following:
  1. Facilitating high-quality, cost-effective, and patient/ family-centered care
  2. Providing linkages among the varied providers within and outside the healthcare organization
  3. Providing linkages between healthcare providers and organizations and MCOs/payers
  4. Influencing a multidisciplinary healthcare team approach that includes patients and their families or caregiver for the planning of care and service delivery
  5. Ensuring optimal services and continuity of care for patients and families, especially after discharge from acute care settings
  6. Brokering community services/resources for patients and their families as deemed appropriate
  7. Ensuring adherence to guidelines and standards of regulatory and accrediting agencies and MCOs
  8. Examining the outcomes of the discharge plans and services provided in preparation for or after discharge
 As noted in the previous section, a particular focus of the continuum of care is coordination of care or services provided by a healthcare organization to meet the ongoing identified needs of individuals. This includes referrals to appropriate community resources and liaison with others, such as the individual patient's physician; other healthcare organizations; and community services involved in care or services. The transitional planning process assists healthcare organizations in the implementation of the plan of care and prevents the use of unnecessary duplication of services. It consists of six steps or phases in the care of the patient. As noted in Figure 1, these are as follows:
  1. Assessment of the patient's condition, risks, and needs
  2. Development of the transitional plan, including the goals of treatment and discharge
  3. Implementation of the plan
  4. Evaluation and ongoing monitoring of the plan
  5. Confirmation of and final preparation for the patient's discharge
  6. Discharge of the patient to another level of care or to home
 The steps in this process, although listed in a linear fashion, are not necessarily linear. They also are not limited to an acute care setting focus, even though the patient may be receiving care while in the hospital at this point (Case Manager's Tip 6). Case managers usually shift back and forth between the steps while engaged in functions such as assessing/reassessing the patient's condition and discharge planning needs, accounting for the latest changes in the patient's condition when revising the plan of care, attempting to confirm the transitional plan with MCOs, and making the final arrangements for transferring a patient to another facility.

Step 1: Assessment of the Patient's Condition, Risks, and Needs
On admission to the hospital and as early as possible, case managers usually screen patients to determine what their needs are and whether these needs may require case management services. As they complete this assessment, they pay special attention to identifying the discharge planning needs and the conditions that will necessitate the transition of patients from one level of care to another. In this assessment, case managers apply criteria for admission to the hospital as indicated, for example, in the Milliman & Robertson or InterQual criteria. To illustrate this point, let us assume that a patient is seen in the ED with a possible stroke and is admitted to the hospital if he or she meets any of the following criteria (these are select examples):
  1. InterQual: inability to move limb(s), unconsciousness, aphasia, need for surgery, uncontrolled seizure activity
  2. Milliman & Robertson: intracranial hemorrhage, hemiparesis, need for physical therapy and/or speech therapy evaluation as a result of the disease, requiring anticoagulation therapy
 Case managers can see in this example that the criteria from InterQual and Milliman & Robertson are essentially the same. In this example, case managers evaluate the appropriateness of the admission to the acute care setting/hospital, which means the transfer of the patient from the ED level of care to the inpatient level of care. Based on the complexity of the patient's condition, that is, the severity of the presenting illness and the intensity of the required resources, the patient may be transferred to either an intensive care unit or a regular inpatient unit as needed. The case manager initiating the preliminary assessment of this patient can also identify the patient's potential postdischarge/hospital needs and include these needs in the transitional plan for follow-up and ongoing evaluation.
     
Institutions may have an ED or an admitting officebased case manager complete such assessment and develop an initial transitional/discharge plan. ED case managers can apply the InterQual or Milliman & Robertson criteria to determine the need and appropriateness to transition a patient from the ED to an inpatient level of care/setting.
    
After admission to the inpatient unit/level of care, inpatient case managers can then follow up on the plan already developed in the ED. They first reassess the patient's condition and needs, then revise the plan of care, including the transitional plan. Next they begin the interdisciplinary process for service delivery planning, facilitation, and coordination. Before developing the transitional/ discharge plan, the case manager should complete a thorough assessment and evaluation of the patient's: Step 2: Development of the Transitional Plan, Including the Goals of Treatment and Discharge
After completing the initial assessment based on the previous list, case managers can develop the transitional plan in conjunction with the interdisciplinary plan of care. The transitional plan must focus on the identified patient problems or areas of deficit and concern. For example, these may be related to the following: As case managers identify and confirm these needs, they establish the goals of the transitional plan that are reflective of the problems identified. Therefore the transitional plan focuses on the issues case managers intend to resolve in conjunction with the patient and family/caregiver and the healthcare team. Before they initiate their action plans, case managers confer with the patient and family and the appropriate members of the healthcare team such as the physicians to approve and finalize the plan. During this step, case managers communicate their expectations of the patient and family and explain their responsibilities to them. For example, case managers may request certain documents that are in the possession of the patient/family and necessary for the Medicaid application. Therefore they may establish a timeline with the patient and family for completing the Medicaid application and follow up with them if they do not meet the timeline.
     
In addition to the transitional plan, case managers focus on the medical plan of care and its impact on transitioning patients from one level of care to another. They usually evaluate the patient's condition and the treatments being provided for their appropriateness to the level of care/setting the patient is in (Case Manager's Tip 7). This is important because of their role in transitioning the patient to the next level in a timely fashion. This function results in preventing reimbursement denials or an unnecessary hospital stay. In addition, this evaluation facilitates the implementation of the discharge/transitional plan. These activities bring to life the act of integrating utilization management and transitional planning for a seamless approach to case management care delivery. For example, when a patient admitted to the coronary care unit because of acute myocardial infarction undergoes uncomplicated angioplasty or a coronary stent placement, the case manager may ensure the patient's transfer to a telemetry or cardiac unit after the procedure. This is indicated because the patient's stable condition no longer meets the criteria for an intensive care setting/level of care. In this case, the case manager not only is expediting the transition of the patient toward discharge but is preventing inappropriate/unnecessary utilization of a higher level of care that may jeopardize reimbursement.

Step 3: Implementation of the Plan
Before the case managers implement the patient's transitional plan, they may arrange for a case conference(s) with the patient and family or the healthcare team. They may elect to conduct the conference either with all parties combined or with the patient and family separate from the team. Such a decision is made based on the complexity of the issues and treatment plan and the concerns to be discussed or by a request from the patient and family, the physician, or the team. Regardless of how the case conference is held, the purpose remains to reach consensus on the plan of care, including the transitional plan, and to answer any challenging questions regarding the care. Some examples of the reasons for holding a case conference are discussing end-of-life issues and decisions about continuing or discontinuing treatment, do not resuscitate (DNR) order, disagreement among family members regarding the plan of care, managed care denial of continuing services, or merely a patient and family education and counseling session.
     
To implement the transitional plan, case managers may need to request the involvement of specialists in the care of the patient such as physical therapy, speech therapy, occupational therapy, pharmacy, home care, pain management, social services, and nutrition. Following predetermined referral criteria facilitates this process and enhances consistency in the delivery of quality care. Examples of these criteria are available in Box 5. Consultations with specialist providers is necessary, especially when a confusing situation arises that requires their intervention and input or because of the need to adhere to the regulations that govern the practice of that particular discipline. For example, a patient may not receive home care services unless assessed by the home care staff first and deemed eligible for home care services after discharge. Another example is the requirement of a rehabilitation evaluation by a physiatrist before establishing a physical therapy plan of care for rehabilitation purposes. Using a list of criteria to clarify the need for referrals is essential for providing better quality of care, eliminating confusion as to when a patient may need the care of a specialist provider, and expediting the implementation of the transitional plan.
     
Other important case management functions in this step of the transitional planning process are patient and family education, managed care authorizations for discharge services, and brokerage of services from community agencies. Case managers may not always be involved in patient and family education; however, they make sure that other providers such as primary nurses provide this service (Case Manager's Tip 8). In some instances it behooves case managers to educate their patients and families or caregivers themselves. Examples of these situations are confusion about aspects of the care such as managed care health plans and how they operate, insurance benefits and entitlements, the authorization and certification process, transitioning the patient to another less complex or more complex level of care, and the need to transfer a patient to a long-term care facility. Sometimes case managers are involved in educating the patient and family about complex care situations or treatment regimens that are unusual to other nursing staff members.
     
As for discharging patients to another care facility such as a nursing home or subacute care, case managers coordinate such a transitional plan with the rest of the healthcare team, the patient and family, and appropriate representatives from the external facility. Depending on the type of the patient's insurance plan, they may also contact the case manager of the MCO for authorization of this type of transition. In the case of a Medicare or Medicaid patient, they apply the eligibility criteria for such transfer available from HCFA or the CMS. If the case managers assuming this role are not social workers, they may consult with social workers for collaboration on such transfers. This aspect of the transitional plan highlights the need for case managers to apply utilization management knowledge and skills while making these plans and the integration of utilization management and transitional planning into a seamless process of care coordination.
     
Patients' transitional plans may sometimes require the coordination of postdischarge services available in the community. These community services are either volunteer and free or reimbursable by the patient's insurance carrier. Examples include the following: If case managers arrange for any reimbursable services, they are required to follow the rules and benefits indicated in the patient's insurance/health plan. For example, in the case of Medicare and Medicaid the eligibility criteria must be consulted when arranging for durable medical equipment. In the case of managed care health plans, case managers must contact the managed care case managers for certification of durable medical equipment before it is arranged for, otherwise reimbursement for such service may be denied.

Step 4: Evaluation and Ongoing Monitoring of the Plan
Evaluation and ongoing monitoring of the transitional plan is important because this aspect of the case manager's role keeps the care provision process in check. Evaluating the transitional plan is essential because it helps case managers determine the plan's continued appropriateness for the patient and ensures that the patient's needs are addressed. However, one cannot evaluate the transitional plan without ongoing reassessment of the patient's medical condition and plan of care. In addition, it is as important to keep abreast of the nuances of care by seeking daily feedback from the patient, family, healthcare team, specialist providers involved in the patient's care, and the representative of any outside agency the patient is referred to for postdischarge services. Based on the new information, case managers usually revise the transitional plan to reflect the changes in patient's condition or wishes regarding discharge services and place.
     
Case managers also evaluate the appropriateness of the level of care being provided based on the patient's latest condition. Again, in this function case managers apply the InterQual or Milliman & Robertson criteria for this purpose. If the patient's condition is found to meet the next level of care and the patient is not yet transitioned, then the case manager facilitates such transfer. He or she may need to meet with the healthcare team and the patient and family to discuss the transfer or to ensure that it is carried out. Other evaluation and monitoring aspects of the case manager's role in this step of transitional planning are as follows: Based on the outcomes of these evaluations, the transitional plan is adjusted as needed. To eliminate conflicts or fragmentation in care, sometimes case managers may resort to a case conference so that agreements are reached and concerns of any member of the healthcare team or patient/family are discussed and resolved. Decisions made during the conference are then implemented in the transitional plan or the medical plan of care as necessary.

Step 5: Confirmation of the Plan and Final Preparation for Patient's Discharge
This step of the transitional planning process focuses on the patient's readiness for the next level of care or discharge. Confirmation of the plan is done while the case manager is evaluating the plan. The decision to transition the patient to the next level of care or discharge is made based on the patient's medical condition and resolution of the problems the patient presented with at the time of admission to the hospital. Other factors that influence this decision are the patient's agreement with the transitional plan, the decision regarding disposition and the date and time of discharge, the position of the MCO/insurance carrier regarding the plan and postdischarge services, readiness of the facility to assume responsibility for the patient's care postdischarge to accept the patient's transfer, and views of the healthcare team, particularly the physician, about the plan and the patient's readiness for it (Case Manager's Tip 9).
     
To determine the appropriateness of the time and condition of a patient's discharge, case managers apply the InterQual or Milliman & Robertson discharge criteria. An example is presented in Box 6. Other criteria are as follows: To determine the most appropriate disposition for a patient, case managers should consider the discharge possibilities based on regulations and admission criteria that may be different for the different facilities or options. Case managers are encouraged to be knowledgeable about these regulations or consult with those who are at their institutions so that appropriate decisions are made and safe, quality, and cost-effective discharge is ensured. Some of the discharge options are as follows: In this step, case managers also revisit the patients' and families' responsibilities toward the transitional plan as agreed on initially after the patient's admission to the hospital and while the plan was being finalized. They examine whether the patient or family made the arrangements they were expected to make, and if not, a decision is made about the next expected step and who is responsible for handling the situation. In addition, case managers are expected to provide the patient, family, or caregiver with a written discharge notice confirming the discharge. This notice acts as a formal and documented notification for discharge, a copy of which usually is kept in the patient's medical record. If the patient and/or family disagree with the discharge, they are entitled to appeal the decision by notifying the peer review organization (PRO). If they appeal, the discharge is then held until a decision by the PRO is reached and the patient and the organization providing the care are informed.
     
A final function of the case managers in this step is confirming the following: Step 6: Discharge/Transferring of the Patient to Another Level of Care
On the day of discharge, the case managers may not be involved in any major activities other than confirming that the discharge takes place as planned. Any change in the patient's condition that may require continued hospitalization is addressed, and the case manager, in consultation with the healthcare team, determines if the discharge should be cancelled. If the discharge is cancelled, then the case manager reapplies the transitional planning process, revises the plan, or develops a new transitional plan reflective of the patient's condition and needs.
     
In this step of the transitional plan, the case manager may answer any final questions the patient/family or the MCO may have. The case manager also provides the facility to be responsible for the postdischarge care (whether a skilled nursing facility, a long-term care facility, or a home care agency) with the appropriate information regarding the patient's condition and the required care. This information is important because it ensures continuity of care.
     
As part of every step of the transitional planning process, case managers are responsible for documenting their plans, interventions, outcomes of coordinating the postdischarge services, and next action steps.
     
It is evident that the transitional planning process is an integral component of case management, and it cannot be completed without consideration of utilization management. Although the discussion presented in this chapter focused mostly on transitional planning, case managers are advised to be careful in their interpretation of this discussion and to consider the steps presented here within the larger context of case management and their roles and responsibilities. At any time and in any given situation, case managers are always applying the concepts of transitional planning, clinical care management, and utilization management into their action plans and the decisions they make to resolve problems. Table 6 summarizes the relationship or correlation between the processes of case management and transitional/discharge planning.

TRANSFERRING PATIENTS TO OTHER FACILITIES

Not every patient is discharged to the home setting after a hospitalization. Some patients may need to be transferred to another facility such as a skilled nursing facility, whereas others may need to be transferred back to the facility they came from before hospitalization. Case managers play an important role in the process of transferring patients from one hospital or level of care to another. They ensure that the transfer packet contains the complete information that is necessary for continuity of care and decision making in the receiving hospital. The transfer information must include the following: It is important to arrange for these documents to prevent patients from being returned to the transferring facility. Sometimes, and in some states, it is required that a pretransfer evaluation be completed and that this evaluation document the appropriateness of the transfer and that the accepting facility approves the transfer before the patient's transfer. Case managers can confirm that such regulations are followed and that such an evaluation is completed before a patient's transfer.
     
In 1998 the CMS passed a regulation regarding transferring Medicare patients that fall in 10 diagnosis-related group (DRG) categories. These DRGs are listed in Table 7. This regulation was passed to curtail the increased number of transfers of patients to subacute care facilities, especially those who are transferred within a few days of an acute care hospital stay. At the time, subacute care was fairly new and not yet under the prospective payment system structure. Acute care institutions found it a rewarding opportunity to transfer patients such as those with strokes, pneumonia, and orthopedic problems early on during their treatment plan for rehabilitation in subacute care settings. Such transfers left acute care hospitals with more desirable lengths of stay and better fiscal states, considering the pressures of the acute care prospective payment system.
     
As stated in the regulation, patients in any of these 10 DRGs are considered transfers if

(1) they were to receive care in a skilled nursing facility or home care after discharge from the hospital,
(2) the services are related to the patient's condition during the hospitalization, and
(3) these services are provided within 3 days of hospitalization. The condition of 3 days can be translated into a rule of not transferring any patient in any of the 10 DRGs before the acute care length of stay reaches the geometric mean length of stay identified in the DRG system. If this happens, the acute care facility will be penalized.
     
Case managers can prevent this penalty from happening and can enhance compliance with this regulation through their role in the transitional/discharge planning process. They can incorporate such a regulation as a criterion of transfer when they evaluate their patients' readiness for discharge or transfer to another facility. They can also educate the rest of the healthcare team about this regulation to improve compliance and prevent the hospital from being penalized by the CMS in case of lack of compliance. Another strategy to increase compliance is for case managers to apply this criterion when they are coordinating postdischarge services for their patients with subacute care facilities or home care agencies. Also refer to tips presented in Case Manager's Tip 10 for more information about patient transfers.

KEY POINTS
  1. Case managers play a pivotal role in ensuring that the transitional plan is safe, timely, and meets clinical criteria such as InterQual or Milliman & Robertson.
  2. The continuum of care can be aggregated into preacute, acute, and postacute care and services.
  3. Matching the patient to the clinically appropriate level of service will result in increased reimbursement to the provider organization.
  4. The case manager should use the steps of assessing, planning, implementing, evaluating, confirming, and transitioning the patient through the continuum of care.
  5. Transitional planning is highly regulated. Case managers should stay up-to-date on all relevant regulations, both at the state and federal levels.
    6.
REFERENCES

American Hospital Association: Guidelines: discharge planning, Chicago, Ill, 1984, The Association.

American Nurses Association: Standards of clinical nursing practice, Kansas City, Mo, 1991, The Association.

Case Management Society of America: Standards of practice for case management, Little Rock, Ark, 1995, The Society.

Commission for Case Manager Certification: CCM certification guide, Rolling Meadows, Ill, 2000, The Commission.

Health Care Financing Administration: State operations manual: inter- pretive guidelines for hospitals, Baltimore, Md, 2001, HCFA. Available online at http://cms.hhs.gov/default.asp?fromhcfadotgov=true (accessed on 11/23/01).

Joint Commission on Accreditation of Healthcare Organizations: Continuum of care. In: Accreditation manual for hospitals, Oakbrook Terrace, Ill, 2001, JCAHO. Available online at http//:www.jcaho.org (accessed on 11/23/01).

Omnibus Budget Reconciliation Act of 1986: Conference report to accompany H.R. 5300, Section 9305, Washington, DC.
Glossary      

Appendix A
Appendix B
Appendix C
Appendix D
Appendix E-1 Appendix E-2 Appendix E-3
Appendix F
Appendix G
Appendix H
Appendix I
Appendix J
Appendix K
Appendix L
Appendix M
Appendix N
Appendix O


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