Discharging planning: When an LTACH makes the most sense
I recently received this question from a colleague:
Mrs. B is expected to need acute care for three to four weeks. There is a bed in a licensed Long Term Acute Care (LTACH) hospital but the family refuses that placement, since it’s an 80-mile drive. We don’t know what to do.
To answer your question: This issue is best resolved with the Utilization Review chairperson (a physician) who works with the patient’s physician. Here are two references: the Social Security Act for Discharge Planning and CMS-10, the Medicare Hospital Manual. In section 290.3 section C of CMS-10, it reads:
A UR committee will consider what facilities are available in the community or local geographic area in deciding whether the patient can be cared for effectively elsewhere. It is not possible to define community or local geographic area with any precision. However, as a general rule, a community or local geographic area should not be defined in such a way as to require a patient to be taken away from his family and transported over great distances.
To locate this document, go to Publication 10: The Hospital Manual, on the CMS website. Here you can open the zipped file and then select: ho_290_ and go to 290.4. Discharge planners, please see see 290.3
You will find, there is nothing preventing a transfer based on geographic preferences–it–it’’s matching what the patient needs and having the physician involved in working with the family to let them know that what the patient needs is most important.
The other reference is the Social Security Act Conditions for Participation for discharge planning; it states that patient preferences should be honored WHEN it is possible to do so.
In this case, however, it may not be possible to honor the patient’s or family’s wishes to not transfer to the most appropriate level of care for the patient.
This is my advice: Since the patient will get more “appropriate” care in an LTACH, the patient should be transferred. LTACH care provides acute care but is more focused on what the patient needs for beginning recovery. It traditionally has more nurse/patient hours per patient and has a focus that is more amenable to patients and specialized in specific care. Here is a website for a good comparison between acute care and long term care hospital.
The patient may be much better off in LTACH: The atmosphere and patient centeredness is more focused. I strongly recommend that the patient be transferred because he/she will receive more specialized care. The LTACH may have an agreement with a hotel/motel for reduced rates for families in such situations. Unless the patient is judged unable to make his/her own decision, this is where you should start.
This is a practitioner issue that must be addressed by the patient’s physician and the accepting physician at the LTACH with input from case managers, social workers, or any other health professional working with the patient. From what limited information I have in the question you’ve asked, this seems like the right decision for the patient.
About the Author: Jackie Birmingham, RN, BSN, RN, BSN, MS, CMA is HCPro's regulatory expert and Vice President for Professional Services, 
Sandra McCune BSN, RN | Mar 28, 2009 | Reply
You cannot issue a HINN or otherwise force a patient to transfer if they need an LTAC level of care, because it’s an acute to acute transfer. If the care required cannot be provided in a SNF or at home with services, you must keep them in the hospital.
Cathy Hamilton | Apr 1, 2009 | Reply
I have issued continued stay denials at our hospital to patients/families who refused to be transferred to an LTAC and our QIO has reviewed the cases and agreed with us that the pt would be reponsible for payment if the pt was not transferred to the appropriate level of care, e.g., LTAC.
Pat Metzger | Apr 8, 2009 | Reply
While I can appreciate your recommendation to transfer, the difficulty appears to be the family’s readiness to sign the appropriate paperwork to get the patient admitted to the LTACH. Without the family’s consent, and if the patient is unable to sign him/herself into the facility, it is unlikely the transfer can take place.
Sandra McCune BSN, RN | Apr 8, 2009 | Reply
I called our QIO to clarify this, & they said even they are not clear whether a HINN 12 can be issued in this situation.
And if it can be issued, they are not clear whether the patient/family must first file a complaint with the QIO.
The guidance from CMS to the QIO’s regarding this has changed several times in the past 1-2 years. I suggest you talk with your individual QIO to determine how they interpret it.
Reta Caputo | Apr 9, 2009 | Reply
I agree that the LTACH is the best plan for the patient. But we are not permitted to send a patient if they refuse to go.
In PA the QIO would not support the facility if we issued the IMM and the family appealed. They would say that we did not have a disposition plan since the family refused transfer to the LTACH.
I would be interested as to what state C. Hamilton is from?
Jackie Birmingham | Apr 9, 2009 | Reply
Have been tracking the replies about the transfer of a patient from ‘acute’ care to LTCH. Getting reinforcement that the input of all involved is necessary. It seems from reading the posts that the QIO involvment is where there is some need for clarification.
The LTCH level of care is – for the original patient- a more appropriate level of care. I’m still stuck on that thought. When the patient’s attending physician agrees that the LTCH is a more appropriate level of care…and the LTCH has a physician who agrees, and the hospital UR agrees, I would go back to the QIO again.
Other than the patient ‘refusing’ on what basis does the QIO make a decision to ‘agree’ with the patient and stand in the way of a discharge to a more appropriate level of care?
If I’m not reading or interpreting the postings accurately, please let me know.
Stay tuned… will explore more. Interesting situation.
Jackie Birmingham
Cathy Hamilton | Apr 9, 2009 | Reply
I am in the state of Florida.
Reta Caputo | Apr 16, 2009 | Reply
Jackie,
Exactly.. But the QIO can and does interpret this as not having a discharge plan in place. I have gone round and round with them that this puts the facility in a “held hostage” situation. The reply to me was, “We understand your predicament, but you must have a safe discharge plan documented.” I know I am not alone getting this reply because my sister facilities in PA report the same reply.
Mike Todai | May 10, 2009 | Reply
Enjoyed reading thought full comments and appropriate discussion. It is easier to work with family to explain why it is in the best interest of the patient. One of the challenges we face is that not every hospital has LTCH within 10 to 30 miles radius. We have been able to send patient 70 miles or away from the hospital town based on what is good for the patient. It does not work every time so we work case at a time. Most of the time attending and especially Intensivist/s were reluctant to let go of the patient out of town. It took some time to break the ice. Most of the hospital had not taken the time to study the cost of avoidable days for keeping patients in the hospital that could be transferred to LTACH and/or rehab. Administration was not educated on cost of keeping such patients.
I have tried to look for what is best for the patient outcome and not just focus on to reduce LOS at acute care hospital. I worked with Medical Director and administrator at the Long term acute care hospital to make it easier for the family to see their loved ones, provide some assistance with transportation and outcomes to attending on regular basis with the assurance that they will get their patient back. It is hard work one case at a time. With good outcomes eventually attending and case managers started trusting the process and it becomes widely accepted.
Most of the hospitals are relying on case managers and physicians to identify patients appropriate for rehab and LTCH. They usually do a good job and now with HIPPA rule may not be able to engage liaisons to help them screen patients early. I have found in some places that they may be missing about 10 to 20% of patients appropriate for such places. Having worked with 110 Acute Rehab hospitals and 15 LTCHs learned that there are other quicker mechanisms to address this and hospitals I have visited are not utilizing it.
I had opportunity to survey low performing 30 ARUs and 10 LTACHs in less than 8 months to identify top reasons or barriers for case managers to send referrals to LTACHs and Rehabs. In all cases the case managers indicated that it was easier for them send patient to a nursing home compared to send one to LTACH and/or Rehab. I also had opportunity visit places they had good practice and I found that their response time and customer service was superior and they did all they could to make it easier for hospitals to send their business. Those who are on LTCH and Rehab side do take a lot longer than they should to screen and accept patient. We designed a work process where a response can be given in one hour to no more than 4 hours. The hospitals were located from Alaska to Main.
Mike Todai
miketodai@comcast.net
678 358 0004
Nancy Meadows | Jun 24, 2009 | Reply
I work with a QIO in provider educator. I agree with Ms.McCune’s response: “You cannot issue a HINN or otherwise force a patient to transfer if they need an LTAC level of care, because it’s an acute to acute transfer. If the care required cannot be provided in a SNF or at home with services, you must keep them in the hospital.” The patient has a right to refuse an acute to acute transfer.
To keep processes truly patient-centered, I usually suggest that providers have a LTACH representative come to a care conference that involves the discharge planner, attending physician, and family to try and come to a joint resolution and to encourage the family to at least do an onsite visit. (I also used this technique when I worked as a hospital case manager in ICU and found it normally worked.
wendy | Jun 29, 2010 | Reply
jackie, i am a hospital cm, and this is off the subject, but i remember you telling us one day when you came to visit, that when the pt is discharged, and then later the family/pt call back wanting more cm services, like outpt therapy or abx, that this should be done by the pt doctors office, since we no longer have a consent to treat in the hospital