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Based on review of hospital policies/procedures, medical records, and interviews, it was determined that the hospital failed to demonstrate that 2 of 5 discharged patients selected his/her home health care agency (HHA), or subacute care facility, from a list of qualified aftercare providers (Patients #1 and 5), as evidenced by:

1. failure to document discharge planning that included a list of subacute care facilities provided to Patient #1; and

2. failure to document discharge planning that included a list of HHAs provided to Patient #5.

Findings include:

The hospital policy titled Discharge Planning - Inpatient #50501 S (last revised 07/11), requires: "...Patients discharged to Skilled Nursing Facilities (SNF), Home Health Care (HHC) and Hospice Care will be given a choice list of Medicare certified facilities and/or agencies in their geographic area. Patient preference will be considered and documented in the medical record...."

1. Patient #1 was admitted on 07/14/12 and remains hospitalized for extensive and aggressive treatment of diagnosed Fournier's gangrene. Medical record documentation revealed the patient's pending plans for discharge to a named subacute rehab facility.

2. Patient #5 delivered prematurely on 05/06/12 and remained hospitalized for birth-related complications and co-morbidities. Medical record documentation revealed the patient was discharged home with a named home health care service.

Neither medical record contained documentation that confirmed the patient/representative made their aftercare selections based on lists provided by the hospital.

Utilization Coordinator RN #5 confirmed there was no documentation that patients/families were provided aftercare choices, during the medical record review and interview conducted on 08/30/12.

Based on review of the hospital's Utilization Management Plan 2012, Quality Plan 2012, supporting documents and interviews, it was determined that the hospital failed to demonstrate that the discharge planning process effectively identified patients who needed discharge planning, plans were adequate, plans were effectively executed, and that data collected was examined to determine the process was effective in providing aftercare and reducing readmissions.

Findings include:

The hospital's Utilization Management Plan 2012, requires: "...Discharge Planning...discharge needs and the availability of post-hospital services are assessed upon admission and re-assessed on an ongoing basis to avoid unnecessary delays in discharge...."

The hospital's Quality Plan 2012, requires: "...Process improvement data is collected, measured, and assessed in a systematic and ongoing manner...to assess variation and the need for improvement...analyze...develop and implement solutions...evaluate results...standardize the solution and capitalize on new opportunities...."

The hospital's NAPH (National Association of Public Hospitals) Safety Network for Preventable Readmissions project requires participation from Care Management, Administration, Quality Management, and Quality members. The hospital initiated their 90-day Action Plan in 01/12 to address preventable and avoidable re-admissions for Medicare patients 64 years and older, as follows:

Discharge follow up phone calls to determining:

Percentage of patients "expecting a visiting nurse"
Percentage of patients reached by phone
Percentage of patients that filled their prescriptions
Percentage of patients who scheduled physician/clinic appointments with 7 - 10 days

Data revealed:

75% (of patients) scheduled aftercare appointments within 7-10 days of discharge
84% received hospital follow up calls 48-72 hours of discharge
89% filled their prescriptions at discharge

Opportunities for improvement:

Increase follow up phone calls from 84% to 87%
Increase scheduled physician/clinic appointments from 75% to 78%.

Interventions proposed: Patient education regarding the importance of post follow up physician/clinic care, identify/establish primary care physician (PCP) on admission, schedule aftercare appointments within 7 days of discharge, and fax discharge summaries to the PCP/clinic within 72 hours of discharge.

The Director of Quality and Care Management and the Manager of Care Management both indicated that the hospital effectively reduced re-admissions, during interviews conducted on 08/30/12 and 08/31/12. The information and documentation provided for review however did not specify what concerns the patients had, how the staff intervened, and how this data could be used to improve the discharge process.

The UR/QM project did not pro-actively identify/specify if patients followed through with their PCP/clinic appointments; if aftercare nurses visited as scheduled; were medical records reviewed to ensure staff assessed the patient correctly and if observations were comprehensive and appropriately documented; did Case Managers visit patients within 24 hours of admission and document discharge teaching (per hospital policy); were medical records reviewed to determine the appropriateness of discharge instructions related to the patient's diagnoses and home care needs; were there appropriate aftercare referrals based on the patient's documented needs; did discharge planning reflect physicians' orders; and did the patient actually receive aftercare services.

The review process did not demonstrate that the hospital implemented a system that required that all patients who needed discharge planning were identified, that discharge plans were adequate and effectively executed, and that data collected was examined to determine the process was effective in providing aftercare to reduce readmissions.