One aspect of nursing home operations that I have seen that could be improved is discharge planning. It seems that once a discharge is being initiated, we do that quickly in an effort to reduce workload. Discharge planning represents many opportunities that many facilities do not take advantage of in many different aspects. With that in mind, I would like to offer or share the following points you may want to consider in your discharge planning process.

1. First, your interdisciplinary team (IDT) should be conducting an IDT discharge meeting with the resident and their responsible party ahead of the actual discharge date. A specific date and time should be set ahead of time that everyone can agree on. I also encouraged the IDT whenever possible to plan discharges right after breakfast. Keep in mind that the business office bills for date of admission but does not bill for day of discharge. Many facilities wait until late into the afternoon to facilitate discharges. When this happens, you are essentially providing free care throughout that day. These expenses add up over time and include staff time, food, supplies, rental equipment, etc. that you will not be able to bill. I know in some cases this may not be possible, but our IDT would make every effort to discharge residents after breakfast.

2. Another area that I would focus on is keeping a precise record of all rental durable medical equipment (DME) that you are using to meet patient care needs. I have seen many instances where accurate records are not maintained and equipment gets lost or misplaced, which then you become responsible for. I have walked by many resident rooms several days after a discharge, and there is rental equipment still left in the room. All rental equipment should be immediately removed from the room after a discharge has occurred. From a financial standpoint, you are better off purchasing this equipment rather than leasing. The lease costs will add up considerably, and you can avoid this expense by purchasing this equipment. 

3. Before the resident leaves the facility, make sure you have some boxes and plastic bags to pack up their belongings. Your staff should be using a Resident Belongings Inventory to check off the resident’s items that were brought in at admission. I would also highly recommend purchasing a hotel luggage cart to transport the resident’s belongings to their vehicle. 

4. For skilled nursing admissions, I would recommend a follow-up call by the IDT within 30 days from the date of discharge. In some situations where a resident may be struggling at home and needs more care, you can bring that residents back into your facility without a qualifying hospital stay and continue their Medicare benefits unless they have been exhausted. I would also ask the admission and business office to identify a secondary payer source for short-term admissions in case their stay is longer than expected. This should be done prior to or at admission. Your social services director, therapy director or nurse case manager would be appropriate to follow up.

5. If you operate a skilled distinct care unit, it is very important that long term care residents are not occupying these short stay rooms. I would also encourage keeping private rooms open for residents with highly complex care. Again, you do not want to tie up your private and skilled beds with long term care residents. These beds need to be available for skilled admissions.

6. One aspect of discharge planning that is vital in obtaining timely feedback from residents who are in the process of being discharged is the completion of a Resident Discharge Satisfaction Survey. I assign my social services coordinator to initiate this survey during the IDT discharge meeting with the resident and their family. This feedback evaluates the resident’s overall stay and whether they would recommend others to your facility. It also identifies any issues that could be resolved before the resident leaves your facility. I would also double check to see that there are no outstanding grievances that may still be unresolved. Survey teams will ask to see your grievance logs so this should also be a facility priority at discharge. This can also be a part of your QAPI process. Here is one example of a survey. 

7. When your IDT meets to facilitate a discharge, make sure that a timely a NOMNOC (Notice of Medicare Non-Coverage) is issued and signed by the resident or responsible party. I have seen many instances where this was not done and potentially puts the facility in a liable situation. This means that the claim could be denied and the facility becomes responsible for the cost of care for that resident for their entire stay. Make sure you also have a trained back-up to assist with this process. 

8. From a marketing standpoint, I used a facility newsletter to continue building on the relationship with discharged residents. Facilities make significant efforts up front to build your census, but keep in mind that many of the residents you discharge could become repeat customers. It is vitally important to retain that relationship that everyone has worked so hard to build. An electronic quarterly newsletter is easy to do. At the time of admission, I would ask for resident or family email addresses to build a list to use for your facility communications. If you are looking to use resident pictures or testimonials for marketing purposes, make sure you get the required authorizations beforehand. These newsletters can also be sent to other referral sources such as discharge planners, case managers, social workers, and physicians. 

9. One thing to keep in mind, especially with HMO and insurance payors, is that they will try to discharge a resident too early, especially if they have Medicaid as a back-up payor. If this happens, be prepared to file appeals on behalf of the resident, especially if they are still receiving skilled services during their stay. If you do not appeal, you will be paid at the Medicaid rate while providing extensive nursing and therapy services. You will need the resident’s approval to appeal any inappropriate or early discharge. 

10. To facilitate a safe and appropriate IDT discharge, I would also recommend a comprehensive discharge checklist to ensure a smooth transition. Many long term care software programs have discharge checklists that can be customized to your facility.

11. Lastly, I would send the resident or responsible party a thank-you letter for considering and choosing your facility for their care needs. This is a good way to build more goodwill and further your relationship with discharged residents and family members. 

Mark Trangsrud is a retired skilled nursing home administrator with over 41 years of experience. He has been licensed in 8 different states as a nursing home administrator as well as serving on the South Dakota and Colorado Health Care Association Boards. He can be reached at Metrangsrud57@msn.com.

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