Why Do Post-Acute Providers Need Access Prior to Discharge?

Many post-acute providers; including home health agencies, private duty agencies, hospices, and home medical equipment (HME) companies; place a high value on use of coordinators/liaisons who regularly visit patient floors at hospitals and other inpatient facilities. Some discharge planners/case managers do not understand why such access is needed, especially in view of the availability of various methods of communicating information to post-acute providers. In fact, discharge planners/case managers may view the presence of post-acute providers as nothing more than a nuisance. There are, however, several reasons why the use of liaisons/coordinators from post-acute providers in institutional settings is important.

First, visits by liaisons/coordinators to patient floors is important for the provision of quality of care for patients. It seems increasingly clear that patients are at greater risk during transitions in care. Such transitions include shift changes in inpatient settings as well as movement from one level of care to another. Care transitions during which patients may be at increased risk also include transitions from inpatient care to post-acute care. According to Standards of Practice for Case Management published by the Case Management Society of America (CMSA) in 1995 and revised in 2002 and 2010, case managers/discharge planners have a duty to assist clients in the "safe transitioning of care to the next most appropriate level."

While discharge planners/case managers may feel that they communicate all necessary information to post-acute providers, it seems likely that the more communication there is prior to discharge, the more likely it is that the transition will go smoothly. In order to help ensure a safe transition, coordinators/liaisons may be present on patient floors in order to talk directly with patients, to obtain more information from discharge planners/case managers, and to meet with families, especially primary caregivers, to help ensure that they understand their role in the provision of home care and hospice services. Consequently, the activities of coordinators/liaisons on patient floors may help to provide optimum transitions to patients from hospital or facility to home, and may help to manage the risks of both hospitals and facilities and post-acute providers.

It is also appropriate for liaisons/coordinators to be on site to visit patients with whom the post-acute provider has an ongoing relationship to help ensure continuity and quality of care. Home health patients whose episodes of care paid for by the Medicare Program do not end while patients are in the hospital or facility are still admitted to home health agencies and are still patients of the agencies. Hospice patients remain admitted for hospice care even though they are hospitalized. Coordinators/liaisons can best stay in touch with patients of their organization and their families by visiting them in inpatient facilities. Post-acute providers need to have current knowledge about the clinical condition of patients, the availability of primary caregivers, etc. in order to be able to continue to provide appropriate care upon discharge. Providers are legally prohibited from rendering services to patients whose needs they cannot realistically meet.

Coordinators/liaisons may also need to be on patient floors because they receive referrals that do not come from anyone at the hospital. Referrals may come from a variety of sources and may be received either verbally or in writing. Examples of referral sources include, but are not necessarily limited to: discharge planners, hospital and facility staff members, physicians, patients, and patients’ friends and family members. It is unnecessary for referrals to be received by the Agency in the form of orders from physicians or other practitioners. Post-acute providers may, for example, receive referrals from family members who seek services for patients. So coordinators/liaisons may need to be on patient floors in response to specific requests from family members to begin the process of coordination of post-acute services.

Based upon the above, liaisons/coordinators have legitimate needs to be on patient floors in inpatient settings. While solicitation of patients is impermissible, violations of this prohibition by some post-acute providers should not interfere with the ability of post-acute providers to meet the legitimate needs described above.

Please do not hesitate to contact us with comments, questions, or requests for additional information.

Elizabeth E. Hogue, Esq.
Office: 877-871-4062
Fax: 877-871-9739
E-mail: ElizabethHogue@ElizabethHogue.net

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