PAGE:1 of 6 / REPLACES POLICY DATED: 3/6/98, 11/12/98, 1/1/06; 11/15/06, 3/1/07, 5/15/10, 10/1/16
EFFECTIVE DATE: February 1, 2017 / REFERENCE NUMBER: LL.HH.016
APPROVED BY: Ethics and Compliance Policy Committee
SCOPE: This Policy applies to HCA Holdings, Inc. (the “Company”) and all of its Affiliates operating in the United States (“HCA Affiliates”).
Other capitalized terms used in this Policy and not otherwise defined have the meaning given to them below in the Definitions section.
PURPOSE: To ensure an acute carehospital (“Hospital”) as part of its Discharge Planning process:
(1) informs the patient (or the patient’s family) of:
(a)their freedom of choice in selecting their Post-Acute Provider/Service;
(b)any Disclosable Financial Interest the Hospital has in the Post-Acute Provider/Service; and
(c)the potential benefit of receiving care from a Post-Acute Provider/Service participating in the Hospital's established preferred provider network relating to a bundled or episode payment model program (e.g., BPCI, CJR, Cardiac EPM, etc.); and
(2) respects, when possible, patient (and family) preferences when expressed.
POLICY: A Hospital, as part of its Discharge Planning process, must inform the patient (or the patient’s family) of their freedom of choice in selecting their Post-Acute Provider/Service. The Hospital must respect, when possible, patient (and family) preferences when expressed. The Hospital must not specify or otherwise limit the qualified Post-Acute Providers/Services that are available to the patient.
In the event a patient is discharged to one of the below enumerated types of Post-Acute Providers/Services, a Patient Choice Letter must be presented to the patient:
- Skilled Nursing Facility (“SNF”)
- Home Health Agency (“HHA”)
- Hospice Care Provider
- Inpatient Rehabilitation Facility/Unit
- Inpatient Voluntary Psychiatric Facility/Unit
- Long Term Acute Care Facility
Discharge Planning services may only be performed by Hospital Case Management Personnel.
The discharge or transfer of patients from a Hospital’s emergency department, and for which the Hospital has obligations under the Emergency Medical Treatment and Active Labor Act ("EMTALA"), is governed by the EMTALA policies and not by LL.HH.016.
DEFINITIONS:
Affiliate: means any person or entity Controlling, Controlled by or under common Control with another person or entity.
Control: means the direct or indirect power to govern the management and policies of an entity; or the power or authority through a management agreement or otherwise to approve an entity’s transactions (includes Controlled, Controlling).
Dependent Healthcare Professionals (or DHPs): as defined in HCA Policy CSG.QS.003 (Vetting Dependent Healthcare Professionals and Other Non-Employees), includes individuals not employed by the Hospital who are permitted both by law and by the facility to provide patient care services under an approved scope of practice. These individuals may be employed by a contractor, a temporary staffing agency, a privileged practitioner or practitioner group or be directly contracted by a patient for a specific service.
Discharge Planning: means a process that involves determining the appropriate post-hospital destination for a patient, identifying what the patient requires for a smooth and safe transition from the hospital to his or her discharge destination, and beginning the process of meeting the patient's identified post-discharge needs.
Disclosable Financial Interest: means the Hospital's direct or indirect ownership interest in, or Control of, a SNF or HHA, or a SNF or HHA's direct or indirect ownership interest in, or Control of, the Hospital.
Hospital Case Management Personnel: means:(1) employees of the Hospital or any Affiliate of the Hospital, such as employed case managers, or (2) independent contractors engaged by, on behalf of, and at the direction of, the Hospital for Discharge Planning purposes.
The following are (non-exhaustive) examples of independent third party individuals or entities that are not Hospital Case Management Personnel (“Non-Hospital Case Management Personnel”): Post-Acute Provider/Services, insurance plans, DHPs, or external navigators.
Patient Choice Letter: A form letter for Hospital Case Management Personnel to use for the documentation of patient choice of Post-Acute Providers/Services, which shall be maintained in the patient's medical record.
Post-Acute Provider/Service: A provider or supplier of post-acute services, includingpost-acute services to inpatients who are: (1) discharged home with an order for post-discharge services, e.g., home health; (2) discharged to a non-acute care setting, e.g., skilled nursing facility; or (3) transferred to another acute care setting, e.g., inpatient rehabilitation facility.
PROCEDURE: The following steps shall be performed to inform the patient (or the patient’s family)of their freedom of choice to select a Post-Acute Provider/Service, and to respect, when possible, patient (and family) preferences when expressed:
Implementation:
- Discharge Planning services may only be performed by Hospital Case Management Personnel.
- Post-Acute Providers/Services
- insurance plans
- DHPs
- external navigators
Please note this Policy is not intended to alter or otherwise limit employees of Hospital or any Affiliate of Hospital who access and utilize pertinent patient information to facilitate patient identification and screening activities that enhance the Discharge Planning process.
- With respect to non-Hospital Case Management Personnel (such as Post-Acute Provider/Service representatives) who are present in the Hospital, the following safeguards must be implemented to avoid actual or perceived inappropriate influence over patients' freedom of choice:
- Non-Hospital Case Management Personnel (e.g., Post-Acute Providers/Services, insurance plans, DHPs, external navigators) shall not be in contact with any patient or patient family/representative regarding Post-Acute Providers/Services until a signed Patient Choice Letter has been obtained by Hospital Case Management Personnel, ensuring the patient has exercised freedom of choice.
- Non-Hospital Case Management Personnel should not wear hospital jackets or tags with the Hospital name. Rather, they should wear name tags with the name of the company or organization they represent visible.
- In addition to the foregoing, with respect to Non-Hospital Case Management Personnel, the Hospital should ensure all applicable requirements of Policy CSG.QS.003 (“Vetting Dependent Healthcare Professionals and Other Non-Employees”) have been met.
- As soon as possible after a decision has been made to send a patient to a Post-Acute Provider/Service, the patient has the right to choose the provider of the service. Only Hospital Case Management Personnel may discuss with the patient his/her right to choose a Post-Acute Provider/Service. Hospital Case Management Personnel may also educate the patient with regard to objective, publicly available quality measures and data related to Post-Acute Providers/Services. In addition, if the Hospital has established a preferred provider network relating to a bundled or episode payment model program (e.g., BPCI, CJR, Cardiac EPM, etc.), Hospital Case Management Personnel may educate the patient on the potential benefit of receiving care from a Post-Acute Provider/Service participating in the Hospital's network.
- Patients referred for Post-Acute Providers/Services must be informed of their freedom of choice in selecting their Post-Acute Provider/Service. The Hospital must respect, when possible, patient (and family) preferences when expressed. The Hospital must not specify or otherwise limit the qualified Post-Acute Providers/Services that are available to the patient.
- In the event a patient is discharged to one of the below enumerated types of Post-Acute Providers/Services, a Patient Choice Letter must be presented to the patient:
- SNF
- HHA
- Hospice Care Provider
- Inpatient Rehabilitation Facility/Unit
- Inpatient Voluntary Psychiatric Facility/Unit
- Long Term Acute Care Facility
If the patient chooses specifically to make no choice of a Post-Acute Provider/Service, then the Hospital must notify the patient who the default Post-Acute Provider/Service will be, and of any Disclosable Financial Interest between the Post-Acute Provider/Service and the Hospital.
If the patient comes to the Hospital from a Post-Acute Provider/Service and requests to return to that same Post-Acute Provider/Service upon discharge from the Hospital, the patient is not required to provide written notice of this choice. Documentation that the patient has requested to return to the Post-Acute Provider/Service of origin should be maintained in the patient’s medical record.
- For discharges requiring SNFs, the Hospital must provide each patient with a list of all SNFs that (i) are available to the patient,(ii) participate in the Medicare program, and (iii) serve the geographic area where the patient resides or the geographic area requested by the patient (the "SNF List"). The SNF List must be updated at least annually. For patients enrolled in a Medicare or Medicaid managed care organization ("MCO"), the Hospital must indicatethe availability of SNFs that have a contract with such MCO. In addition, before the patient makes his/her choice, Hospital Case Management Personnel must identify SNFs in which the Hospital has a Disclosable Financial Interest either through designation on the SNF List or on the Patient Choice Letter.
- For discharges requiring HHAs, the Hospital must provide each patient with a list of all HHAs that (i) are available to the patient, (ii) participate in the Medicare program, (iii) serve the geographic area in which the patient resides, and (iv) have requested to be listed by the Hospital (the “HHA List”). The HHA List must be updated at least annually. For patients enrolled in a MCO, the Hospital must indicatethe availability of HHAs that have a contract with such MCO. In addition, before the patient makes his/her choice, Hospital Case Management Personnel must identify HHAs in which the Hospital has a Disclosable Financial Interest either through designation on the HHA List or on the Patient Choice Letter.
REFERENCES:
- 42 U.S.C. § 1395x(ee)(2)-(3)
- 42 U.S.C. § 1395lll(i)
- 42 C.F.R. § 482.43
- HCA PolicyLL.EM.001
- HCA PolicyLL.MBP.001et seq.
- HCA PolicyCSG.QS.003
- EMTALA policies
Patient Choice Letter - Used for patients selecting SNF, HHA, Hospice, Inpatient Rehabilitation Facility, Inpatient Voluntary Psychiatric Facility, or LTAC services.
Dear Patient and Family:
Your physician has ordered/recommended additional or continued services after you leave the Hospital. Please note some providers may be affiliated with, and/or owned or controlled by, the Hospital or may participate in the Hospital's established preferred provider network relating to a bundled payment program (e.g., BPCI, CJR).
____The provider you selected is affiliated with, and/or owned or controlled by, the Hospital.
____The provider you selected is a participant in the Hospital's established preferred provider network relating to a bundled payment program (e.g., BPCI, CJR).
You have the right to select any provider to provide the care ordered/recommended by your physician. This is your choice.
When discharging to a home health agency or skilled nursing facility include: A list of home health care providers who have asked the Hospital to be so listed, and/or skilled nursing facility providers, is being provided for your review and decision making.
For all other post-acute providers/services: If you need more information before making this decision, our discharge planning staff will be glad to assist and provide you with a list of alternative providers for your review and decision making.
Please be aware that some insurance companies have contracts with specific agencies, providers, and facilities which may dictate which post-acute provider/service you can use. If you choose a post-acute provider/service that is not a provider under your insurance plan or not Medicare certified, you could be liable for the expense incurred. Because we are unfamiliar with the policies and procedures of the providers other than the one listed below, we cannot make any recommendations concerning them.
Patient/Representative:
Please acknowledge that you received the list of home health agencies or skilled nursing facilities: ______(Initial)
OR
Please acknowledge that you declined the list of home health agencies or skilled nursing facilities: ______(Initial)
I hereby choose to use
Patient Signature:
Date/Time:
Surrogate/Guardian Signature:
Relationship:
Date/Time:
Verbal Consent Obtained From: ______
Verbal Consent Obtained By: ______
Reason for Verbal Consent: ______
Patient ChoiceLetter – For patients receivingservices at a Hospital-affiliatedInpatientRehabilitation Facility.
Dear Patient and Family:
Your physician has ordered a pre-admission assessment to determine if you would benefit from an Inpatient Rehabilitation Program prior to returning home. Below are facilities which are affiliated with, and/or owned or controlled by, the Hospital, which can provide the assessment services recommended by your physician.Note, however, there are other Inpatient Rehabilitation Programs in this area that are not affiliated with the Hospital.
In fact, you have the right to select any provider to conduct this pre-admission assessment and to provide the care recommended by your physician. This is your choice. If you need more information before making this decision, please ask our discharge planning staff who will be glad to assist and provide you with alternatives.
Please be aware that some insurance companies have contracts with specific agencies, providers, and facilities which may dictate which Inpatient Rehabilitation Program you can use. If you choose a company that is not a provider under your insurance plan or not Medicare certified, you could be liable for the expense incurred. Because we are unfamiliar with the policies and procedures of the providers other than the one listed below, we cannot make any recommendations concerning them.
Patient or Family: Please check one of the following:
_____ I hereby choose to use the Hospital affiliated Inpatient Rehabilitation Program: (please check the selected facility below)
Other preference: ______
Patient Signature: ______
Date/Time: ______
Surrogate/Guardian Signature : ______
Relationship: ______
Date/Time: ______
Verbal Consent Obtained From: ______
Verbal Consent Obtained By: ______
Reason for Verbal Consent: ______
Attachments to LL.HH.016
October 2016