When you select a facility in the Explore page or Home page, OR from Recent Providers, the Analyze page opens for the facility you choose. The information on the Analyze page is provided to give you insight into the operations and patient demographics for the selected facility. The Discharge Events by Setting table can be found by clicking on the tab - Utilization and Quality.
Mastery of The Discharge Events table(s) will increase your understanding of the challenges faced by discharge planners and case managers, so you are better prepared to become a trusted adviser and influence how they approach patients during discharge.
This table provides a handful of useful details about the following:
- Patient flow - This table shows the flow of discharges from a specific setting within a facility to a spread of post-acute care options. The specific setting is found in the table name; so, for the table shown below, we are counting discharges from inpatient care. See Settings, below.
- Discharges Instructed - This is the count of discharges coded for the type of post-acute care listed in each row. A discharge will have a single status.
- Discharges who Adhered - This count is a subset of the Instructed column. Every discharge will either be admitted to the coded post-acute care or not. The Adhered count is the number of patients who were admitted to the post-acute setting indicated in the status coding at discharge. This number is used to generate the Adherence Rate, the rightmost column in this table. See below.
- Discharges who Entered - This is the count of all discharges who were admitted to the post-acute setting in each row.
- Opportunities - The two columns, Instructed, not Adhered, and Entered without Instructions include the metrics that are the highlight of this table. These are the gaps that suggest a course of action. See Usage below.
Discharge Events vs. Patients
Please note that the counts in this table are discharge events, not distinct patients. This means that:
- Counts - Discharge counts from this table will not match patient counts from other tables.
- Example - On the Explore page, for example, the number in the Patients coded for Home Health Care column reflects a distinct patient count; a patient is counted once no matter how many claims were submitted for that patient during the reporting period. In the Discharge Events table, that same patient would be counted for every discharge event. See Patient Comparison below.
- Advantage! - As counts of discharges, you can get a sense of the number of events where possible interventions can lead to referrals.
For those of you familiar with the Original Trella Health solution, this table includes the first third of the Post-Acute Destinations (PAD) table with some enhancements. The other two thirds of the PAD table are in a table further down on the page, Outcomes by Setting.
In general, you will use this table to get a sense of patient flow between the "source" setting and your type of post-acute care. Your goal is to identify facilities you can engage to assist with discharge planning and communication in order to increase patient compliance. Let's take a look at discharge optimization and then the two specific opportunities this table displays.
Background - Discharge Optimization
Although the optimal approach to discharge will vary from hospital to hospital based on their patient population and the hospital's strategy to support it, analyzing the hospital's approach to discharge can identify areas of opportunity. Sometimes the hospital itself hasn't performed this analysis and sharing it with them positions you as a value added partner for them! Questions you can answer include:
- What is the hospital's rate of discharge coding to a post-acute setting?
- What is the patients' rate of adherence to discharge instructions and how does it compare to national and state averages?
- How many and what percent of patients are entering a post-acute setting without being coded to do so?
The diagram below depicts the discharge process from a coding, adherence, and admission perspective using an example of 100 patients. The green arrows represent the patient flows where an increase would likely result in more patients being admitted to hospice. Creating conversations about these flows, may help you discover an opportunity to support the hospital's goals AND increase the flow of patients to your agency. Specifically the opportunities are:
- Increase the number of patients that are coded for your care setting.
- Increase the number of patients that adhere to their discharge instructions.
- Increase the number of patients that enter your care setting shortly after discharge regardless of the discharge instructions.
Higher than average % Readmitted: 30 days or 30 Day Mortality rates may point to an opportunity to increase the use of home health. In particular, readmission penalties are a substantial motivator for the hospital. If you can show that alternative care settings have higher than normal mortality rates, higher than normal readmission rates, and home health has a lower than normal utilization rate, then you can make a strong case for better promotion of home health during the course of care and discharge at the hospital!
There are two perspectives on adherence that this table reveals. As we look at these, we will use a single row of the table for examples. In either case, large numbers in these columns suggest that the source facility could benefit from expertise and support from you to get the patients to the appropriate care settings.
Although we are showing the row for home health, the calculations are identical for all types of post-acute care in the table.
Instructed, not Adhered
When a facility discharges a patient to a specific post-acute setting, the hope is that the patient will be admitted to that type of care. To find out how many discharges were not admitted to the intended post- acute care within 30 days, we subtract Adhered, from Instructed:
8,287 - 5,679 = 2,608.
Even under the best possible circumstances, not every patient is going to enter the intended post-acute care. Nevertheless, in this case, we would want to work with the source facility to help discover what happened to those 2,608 discharges.
- Was the appropriate status code indicated for this patient at discharge? Which might be better asked, was the appropriate post-acute care identified for the patient?
- Was the correct information about post-acute needs communicated to the patient?
- Is discharge staff appropriately trained to provide the correct information to the patient?
- What can I do to help this facility get to the appropriate post-acute care? (Which converts easily to, How can I get these discharges converted to referrals?)
Entered without Instructions
This metric is the other side of the adherence coin. This is the count of the discharges who were admitted to the listed type of care in each row within 30 days of discharge, but the initial status coding at discharge was not aligned to the patient's post-acute destination. How in the world did they get here? To get this count, we subtract Adhered from Entered:
9,105 - 5,679 = 3,426
This number tells us something significant. We must assume that a discharge admitted to post-acute care (Entered) was appropriate for that type of care at discharge. Why weren't they coded appropriately?
Many of the same questions from above apply, but the focus with this metric is where you as a post -acute provider can really shine: How can you help the source facility to identify the appropriate level of care at discharge? When this number is large, you have an opportunity to provide meaningful assistance through training or patient evaluation.
To calculate this metric, we divide Adhered by Instructed and multiply by 100%:
5,679 / 8,287 X 100% = 68.53%
The ideal is for this number to be as close to 100% as possible.
Instructed? Do you mean, like a referral?
|It is important to note that when we use the word, "instructed" in this table, we are inferring that patient instruction took place. There is nothing in the claim that indicates what was communicated to the patient. The claims only indicate the documented intention for the next step in the care path at the time of discharge. This intention is indicated by a status code on the claim. For more information, see How does Trella Health Identify Discharge Status Coding?|
|But really, that is the point. We know the count of discharges coded for each post-acute destination, and the adherence to that intended outcome. A large failure in adherence to the coded post-acute intention is indicative of an opportunity for you to intervene and provide assistance at discharge; with the opportunity to gain some referrals.|
Settings - Inpatient, Outpatient, and SNF
Each care setting at a hospital or SNF has its own Discharge Events by Setting table. For instance, a general acute care hospital has a table for both Inpatient and Outpatient. A SNF will have a Table for Outpatient and SNF. The metrics and how we calculate them for each setting are the same. The difference between the tables is the claim type submitted. The three tables are:
- Discharge Events by Setting: Inpatient
- Discharge Events by Setting: Outpatient
- Discharge Events by Setting: SNF
Hospitals will have tables for inpatient and outpatient. For a hospital, the SNF table will be blank.
What if I see metrics in the SNF table?
Although this is pretty rare, some hospitals have Skilled Nursing Units attached to the hospital facility and will submit SNF claims through the hospital's NPI.
SNF's will submit claims for Skilled Nursing and for Outpatient services. If you are viewing a SNF on the Analyze page, the inpatient table will always be empty. SNFs can't submit inpatient claims.
It is possible that a patient could be admitted to more than one post-acute setting within the 30 days after discharge. Each pair of discharge and admission events within 30 days will be counted in the appropriate column. Example: A patient is discharged with a status for SNF, and is admitted to a SNF, but is then admitted to hospice, all within 30 days. The following would receives "counts" in this scenario
|INP to HOS||X||X|
|INP to SNF||X||X||X|
What is "other?"
At the bottom of the Discharge Events table you will see the category, "other." The vast majority of post-acute care is handled by the six categories listed in the table; HHA, HOS, IRF, LTCH, SNF, or No PAC (home). These are aligned in the table based on the codes in the table below. All other codes are collected under "Other."
We determine the "destination" for each row based on the code indicated in Box 17 - Patient Status, from form UB-04 (CMS 1450).
Although possible codes for this field could be 0-99, only 17 are defined - the rest are "reserved for national assignment." We identify the six post-acute care settings using the codes in the table below. ALL other codes are aggregated into the category, "Other." Because the statuses that generate this aggregated count provide no insight into the selected facility or post acute care provided, we do not create a metric for those patients who were instructed who received the matching care or those who entered the care setting within 30 days of discharge. Those two columns will always have a "-" for the "Other" row. It is important to note that some of these "other" statuses have no meaningful post-acute referent.
|Post-Acute Destination||Status Code|
Inpatient to Inpatient Rehabilitation Facility (IRF)
|Inpatient to Long Term Care Hospitals (LTCH)||63|
|Inpatient to Home Health Agency (HHA)||06|
|Inpatient to Hospice (HOS)||40, 50,51|
|Inpatient to Skilled Nursing Facility (SNF)||03|
|Inpatient to Home or Self Care (No PAC)||blank, 0, 00, 01 (01 is the suggested code.)|
Why are the Instructed New and Resumption HHA counts empty?
The Discharge Events tables include three rows of metrics that track discharges to Home Health Care. Once we determine the "counts" for each column, reflected in the row, "INP to HHA (Total)," we then separate those counts into two categories differentiated by whether the subsequent episode of care is a new episode or a resumption of care. A billing episode is considered a resumption of care if the care is provided as a continuation of a prior billing episode. If there was no prior home health care provided, the episode is considered new.
In the image above, the two metrics in the box will always be empty. Even though the discharge claim identifies post-acute status at the time of discharge, there is nothing on the discharge claim to identify whether the subsequent Home Health Care will be a new episode or a resumption of care.
Patient comparison - Explore and Analyze
For this example we will start on the Explore page and look at AdventHealth Orlando. The count of patients discharged from the hospital's inpatient setting is 6,324 patients.
But if we look at the Discharge Events table, the count is 8,287 discharges.
What does this mean?
If you compare the two numbers,
- Patients - 6,324
- Discharges - 8,287
you can see that almost 2,000 patients must have been admitted to inpatient care and then discharged, more than one time. Or, some patients were admitted and discharged multiple times.
The patient number, then gives you a count of the number of patients who were considered home health appropriate at discharge. So, if all of them were admitted to home health care at your agency, you would treat 6,234 patients from AdventHealth during that year.
But some patients are in and out of inpatient care, so the discharges number indicates the number of times you would need to admit those patients (new or resumption of care) during that year to treat them all. If you are wrestling with your competitors for those referrals, you will have 8,287 chances to gain 6,324 referrals. Go get 'em!