by Timothy Gieseke MD, CMD

As private pay PA / LTC patients enter the age of value based purchasing, its clear that CMS expects the private system to become fully integrated like the Kaiser Permanente system has become.  CMS is changing our reimbursement system to encourage tighter coordination of care. AMDA's most recent e-newsletter has the latest update on the 30 day readmission measure for SNFs along with a link to the SNF Value Based Purchasing Program.  

In Sonoma County about 4 years ago, the local KP Continuity of Care Team piloted a program where all their SNF discharges would require a formal dictated discharge summary with accurate medication reconciliation (NPs do this) prior to the discharge of the patient.  This was done in part at the request of their PCPs who were having difficulty assuming first visit care, due to the complexities of SNF care and the inability of patients to recall their meds.  This was not an easy project, but was standardized in their EPIC EHR system.  In addition, it became clear that this program should be extended to the ER and Hospitalist programs.  This made the process of medication reconciliation much easier for all providers and less time consuming.  KP in Northern California has a Home Health Agency (HHA) which services their outpatients.  It’s now their policy to not accept a referral from a SNF until the referring source has done medication reconciliation.  This program has become so successful that the whole KP system has adopted it.  As one of my NP friends at KP said recently, it’s now easy for everyone to identify medication discrepancies and to address them in a timely fashion.  

How do your facility care transitions for your private-pay patients compare to this process?  In my area, a few physicians including myself are dictating comprehensive discharge summaries prior to discharge and are doing medication reviews with an attempt at medication reconciliation.  However, the vast majority of patients are still receiving traditional care with discharge off site by fax with a cryptic written discharge summary done within 1 month of discharge and no medication reconciliation.   

I believe our patients are not well served by this traditional care, which was well exposed in the OIG (Office of Inspector General) study of SNF quality of March 2015.  In the new CMS revisions of our regulations (Mega-Rule), facilities will be required to have in person physician or NP visits prior to discharging patients.

We will have some time to comply with this new regulation, but it's clear that early compliance will benefit our patients, partners, and bottom line.

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