Group Discussion 3, Module 5 Group 4: Alexis Ruffin, Kendra Scott, Britney Smith, Quatavia Stokes, Eloisa Velasquez, Raven Vilo, Charia Williams, LaToya Williams Department of Nursing and Allied Health, Norfolk State University HSM 331-90: Health Financial Management Dr. Batrina Martin April 03, 2022 #1. Who should be financially responsible for the costs related to Mr. Jones’s latest admission? Gholizadeh, M., Janati, A., Delgoshaei, B., Gorji, H. A., & Tourani, S. (2018). Implementation requirements for patient discharge planning in the health system: a qualitative study in Iran. Ethiopian Journal of Health Sciences, 28(2), 157. https://doi.org/10.4314/ ejhs.v28i2.7 Gholizadeh explains how prior to a patient being discharged, all information should be gathered to discuss with the patient and/or a family member which is why it is a vital piece in the health system flow in many countries. According to the article, successful discharge planning has long been identified as the cornerstone of an effective transition of individuals from a hospital to their home. It also explains how the discharge phase of a hospital stay requires several components, including assessment of a patient's current needs, appropriate anticipation of continuing care needs, and recognition of available resources to meet after-hospital care needs. This article examines how discharge planning promotes the quality of inpatient care and reduces unplanned hospital readmission. Gholizadeh reports on preventing certain readmissions has the potential to improve both the quality of life for patients and the financial well-being of healthcare systems. The author also how improvements in hospital discharge planning can significantly improve health outcomes for patients as they move to the next level of care. Howard-Anderson, J., Busuttil, A., Lonowski, S., Vangala, S., & Afsar-manesh, N. (2016). From discharge to readmission: Understanding the process from the patient perspective. Journal of Hospital Medicine, 11(6), 407–412. https://doi.org/10.1002/ jhm.2560 Howard-Anderson reports that by engaging patients or patients for future interventions, including better symptom management and self-care planning prior to discharge, along with more clarity in discharge instructions, promoting awareness of outpatient resources, and improved alignment of patient and provider attitudes, readmissions could potentially be reduced. Smeraglio, A., Heidenreich, P. A., Krishnan, G., Hopkins, J., Chen, J., & Shieh, L. (2019). Patient vs provider perspectives of 30-day hospital readmissions. BMJ Open Quality, 8(1), e000264. https://doi.org/10.1136/bmjoq-2017-000264 Smeraglio reports since it is the healthcare providers responsibility to provide patients with clear instructions before their discharge, the financial responsibility should not fall on Mr. Jones. The author explains how many readmitted patients often feel that the hospital system contributed to their readmission. Since Mr. Jones was readmitted, he may eventually express the same concerns. Nowicki, M. (2017). Introduction to the Financial Management of Healthcare Organizations, Seventh Edition (Gateway to Healthcare Management) (7th ed.). Health Administration Press. This article supports the idea that because the skilled nursing home had an internal auditor, they should be financially responsible for Mr. Jones’s most recent admission. It was the hospital's job to explain that information because proper discharge instructions have the potential to prevent readmissions and enhance the quality of a patient’s life. #2. Should Medicare, or any insurer, pay for readmissions related to errors in discharge instructions? Due to the lack of communication from the hospital , the hospital should be held accountable for Mr. Jones readmission. In the case study it is stated “ The admitting physician discovered that no one at the hospital or skilled nursing facility explained to Mr. Jones the importance of maintaining a low-sodium diet.” It was the charge nurse/ discharge nurse, case manager, to have noticed that Mr. Jones was not well enough to be discharged. Given 4 days in the hospital for his repeat symptoms, Mr. Jones' assigned physician should have been updated on his condition and discharging him should have not been a consideration. Reimbursement for health services are based on certain criteria, which includes, but not limited to high-quality, cost-effective care. The Accountable Care Organization, ACO, was created in 2007, and “mandates provider accountability” (Nowicki, 2018). As an ACO, health care providers, hospitals, and doctors work together to give high-quality care to Medicare patients, with a goal to avoid repeat services and medical errors. ACOs are to “engage in reliable performance measurement techniques that instill confidence in the quality of care provided” The (Kavita K. Patel, 2015). Hospital Readmissions Reduction Program is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans, and in turn reduce avoidable readmissions. Hospital Readmissions Reduction Program (HRRP) https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment /AcuteInpatientPPS/ReadmissionsReduction-Program The program supports the national goal of improving healthcare for Americans by linking payment to the quality of hospital care( gov, 2021). The Affordable Care Act established the hospital Readmission Reduction Program in 2012. Under this program hospitals are financially penalized if they have higher than expected risk-standardized 30-day readmission rates for acute myocardial infarction,heart failure , and pneumonia. Hospitals readmission measures have been touted not only as a quality measure, but also as a means to bend the healthcare cost curve( gov,2012). Hospital readmissions are associated with favorable patient outcomes and high financial costs (gov,2012). The Medicare Payment Advisory Commission has estimated that 12% of readmissions are potentially avoidable (gov,2012). Leeann N. Comfort, S. M. (2018). Medicare Accountable Care Organizations of Diverse Structures Achieve Comparable Quality and Cost Performance. NCBI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6052017/ This article compares three ACO types; physician-led, integrated, and hybrid in quality, spending and likelihood to achieve savings. Research shows that ACOs that are independent primary care providers tend to save more money than hospital-integrated medical groups. This supports Mr. Jone’s case scenario in that he visited a hospital versus a primary care physician or family practice, which resulted in less attentive care, leaving the hospital responsible for lack of communication. #3. Would it be different if Mr. Jones received instructions for a low-sodium diet but chose to ignore them? Yes, it would be different if Mr. Jones encountered instructions for a low sodium diet and chose to ignore them. With that being stated, if Mr. Jones chose to avoid the discharge instructions that were given to him, he is basically implying that he does not care. In this example, Mr. Jones entered a nursing facility and no one gave him a clear explanation of what a low sodium diet is, and why it was important for him to abide by it. When adapting a low sodium diet, physicians tend to suggest that family members assist their loved ones to ensure compliance and understanding of what is required of them. Also, physicians convey a plan of action technique that best suits the patient to follow. In Mr. Jones’ defense, he probably was unsure of what was happening to him and just took what was given, because of the condition he was in. Tending for elderly patients like Mr. Jones and having a discussion on their well being is critical to have. Nonetheless, having the conversation gives important information to continue healthier decisions to maintain independence or safety. Lennie, T. A., Chung, M. L., & Moser, D. K. (2013, September). What should we tell patients with heart failure about sodium restriction and how should we counsel them? Current heart failure reports. Retrieved April 1, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3774591/ The article relates to this discussion because Mr. Jones was not given any instruction. The article explains the correct ways to handle elderly patients going through congestive heart failure. Being on the low sodium diet, and evidence based solutions that can decrease his risk of becoming hospitalized. It also gives insight on what is commonly recommended for a person in his situation to avoid the rise in fluid and swollen ankles. U.S. Department of Health and Human Services. (n.d.). Talking with older patients about sensitive topics. National Institute on Aging. Retrieved April 1, 2022, from https://www.nia.nih.gov/health/talking-older-patients-about-sensitive-topics This article connects with the discussion, it justified how to communicate with elderly patients without avoiding unnecessary awkwardness. Some techniques used to approach sensitive subjects is to directly console the given situation, as well as having resources for more information or support to patients. In the discussion they failed to present Mr. Jones instructions on how to prevent another heart failure episode. Kalogeropoulos, A. P., Georgiopoulou, V. V., Murphy, R. A., Newman, A. B., Bauer, D. C., Harris, T. B., Yang, Z., Applegate, W. B., & Kritchevsky, S. B. (2015). Dietary sodium content, mortality, and risk for cardiovascular events in older adults. JAMA Internal Medicine, 175(3), 410–419. https://doi.org/10.1001/jamainternmed.2014.6278 This article is in accordance with this discussion because it informs us of the dietary sodium intake in older adults. Taking in too much sodium can lead to major health problems for an older person like cardiovascular disease, or heart failure. With this being said without Mr. Jones knowing any different instructions from his normal day the blame can not be placed on him and what can happen to him if the sodium intake does not improve in any way. References Gholizadeh, M., Janati, A., Delgoshaei, B., Gorji, H. A., & Tourani, S. (2018). Implementation requirements for patient discharge planning in the health system: a qualitative study in Iran. Ethiopian Journal of Health Sciences, 28(2), 157. https://doi.org/10.4314/ ejhs.v28i2.7 Howard-Anderson, J., Busuttil, A., Lonowski, S., Vangala, S., & Afsar-manesh, N. (2016). From discharge to readmission: Understanding the process from the patient perspective. Journal of Hospital Medicine, 11(6), 407–412. https://doi.org/10.1002/jhm.2560 Hospital Readmissions Reduction Program (HRRP) https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment /AcuteInpatientPPS/ReadmissionsReduction-Program Kalogeropoulos, A. P., Georgiopoulou, V. V., Murphy, R. A., Newman, A. B., Bauer, D. C., Harris, T. B., Yang, Z., Applegate, W. B., & Kritchevsky, S. B. (2015). Dietary sodium content, mortality, and risk for cardiovascular events in older adults. JAMA Internal Medicine, 175(3), 410–419. https://doi.org/10.1001/jamainternmed.2014.6278 Kavita K. Patel, J. E. (2015). Accountable Care Organizations. AHA Journals. Leeann N. Comfort, S. M. (2018). Medicare Accountable Care Organizations of Diverse Structures Achieve Comparable Quality and Cost Performance. NCBI. Lennie, T. A., Chung, M. L., & Moser, D. K. (2013, September). What should we tell patients with heart failure about sodium restriction and how should we counsel them? Current heart failure reports. Retrieved April 2, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3774591/ Nowicki, M. (2017). Introduction to the Financial Management of Healthcare Organizations, Seventh Edition (Gateway to Healthcare Management) (7th ed.). Health Administration Press. Smeraglio, A., Heidenreich, P. A., Krishnan, G., Hopkins, J., Chen, J., & Shieh, L. (2019). Patient vs provider perspectives of 30-day hospital readmissions. BMJ Open Quality, 8(1), e000264. https://doi.org/10.1136/bmjoq-2017-000264 U.S. Department of Health and Human Services. (n.d.). Talking with older patients about sensitive topics. National Institute on Aging. Retrieved April 1, 2022, from https://www.nia.nih.gov/health/talking-older-patients-about-sensitive-topics Appendix A Group Discussion 3, Module 5 Group 4: Alexis Ruffin, Kendra Scott, Britney Smith, Quatavia Stokes, Eloisa Velasquez, Raven Vilo, Charia Williams, LaToya Williams Department of Nursing and Allied Health, Norfolk State University HSM 331-90: Health Financial Management Dr. Batrina Martin April 03, 2022 #1. Who should be financially responsible for the costs related to Mr. Jones’s latest admission? Gholizadeh, M., Janati, A., Delgoshaei, B., Gorji, H. A., & Tourani, S. (2018). Implementation requirements for patient discharge planning in the health system: a qualitative study in Iran. Ethiopian Journal of Health Sciences, 28(2), 157. https://doi.org/10.4314/ ejhs.v28i2.7 Gholizadeh explains how prior to a patient being discharged, all information should be gathered to discuss with the patient and/or a family member which is why it is a vital piece in the health system flow in many countries. According to the article, successful discharge planning has long been identified as the cornerstone of an effective transition of individuals from a hospital to their home. It also explains how the discharge phase of a hospital stay requires several components, including assessment of a patient's current needs, appropriate anticipation of continuing care needs, and recognition of available resources to meet after-hospital care needs. This article examines how discharge planning promotes the quality of inpatient care and reduces unplanned hospital readmission. Gholizadeh reports on preventing certain readmissions has the potential to improve both the quality of life for patients and the financial well-being of healthcare systems. The author also how improvements in hospital discharge planning can significantly improve health outcomes for patients as they move to the next level of care. Howard-Anderson, J., Busuttil, A., Lonowski, S., Vangala, S., & Afsar-manesh, N. (2016). From discharge to readmission: Understanding the process from the patient perspective. Journal of Hospital Medicine, 11(6), 407–412. https://doi.org/10.1002/ jhm.2560 Howard-Anderson reports that by engaging patients or patients for future interventions, including better symptom management and self-care planning prior to discharge, along with more clarity in discharge instructions, promoting awareness of outpatient resources, and improved alignment of patient and provider attitudes, readmissions could potentially be reduced. Smeraglio, A., Heidenreich, P. A., Krishnan, G., Hopkins, J., Chen, J., & Shieh, L. (2019). Patient vs provider perspectives of 30-day hospital readmissions. BMJ Open Quality, 8(1), e000264. https://doi.org/10.1136/bmjoq-2017-000264 Smeraglio reports since it is the healthcare providers responsibility to provide patients with clear instructions before their discharge, the financial responsibility should not fall on Mr. Jones. The author explains how many readmitted patients often feel that the hospital system contributed to their readmission. Since Mr. Jones was readmitted, he may eventually express the same concerns. Nowicki, M. (2017). Introduction to the Financial Management of Healthcare Organizations, Seventh Edition (Gateway to Healthcare Management) (7th ed.). Health Administration Press. This article supports the idea that because the skilled nursing home had an internal auditor, they should be financially responsible for Mr. Jones’s most recent admission. It was the hospital's job to explain that information because proper discharge instructions have the potential to prevent readmissions and enhance the quality of a patient’s life. #2. Should Medicare, or any insurer, pay for readmissions related to errors in discharge instructions? Due to the lack of communication from the hospital , the hospital should be held accountable for Mr. Jones readmission. In the case study it is stated “ The admitting physician discovered that no one at the hospital or skilled nursing facility explained to Mr. Jones the importance of maintaining a low-sodium diet.” It was the charge nurse/ discharge nurse, case manager, to have noticed that Mr. Jones was not well enough to be discharged. Given 4 days in the hospital for his repeat symptoms, Mr. Jones' assigned physician should have been updated on his condition and discharging him should have not been a consideration. Reimbursement for health services are based on certain criteria, which includes, but not limited to high-quality, cost-effective care. The Accountable Care Organization, ACO, was created in 2007, and “mandates provider accountability” (Nowicki, 2018). As an ACO, health care providers, hospitals, and doctors work together to give high-quality care to Medicare patients, with a goal to avoid repeat services and medical errors. ACOs are to “engage in reliable performance measurement techniques that instill confidence in the quality of care provided” The (Kavita K. Patel, 2015). Hospital Readmissions Reduction Program is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans, and in turn reduce avoidable readmissions. Hospital Readmissions Reduction Program (HRRP) https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment /AcuteInpatientPPS/ReadmissionsReduction-Program The program supports the national goal of improving healthcare for Americans by linking payment to the quality of hospital care( gov, 2021). The Affordable Care Act established the hospital Readmission Reduction Program in 2012. Under this program hospitals are financially penalized if they have higher than expected risk-standardized 30-day readmission rates for acute myocardial infarction,heart failure , and pneumonia. Hospitals readmission measures have been touted not only as a quality measure, but also as a means to bend the healthcare cost curve( gov,2012). Hospital readmissions are associated with favorable patient outcomes and high financial costs (gov,2012). The Medicare Payment Advisory Commission has estimated that 12% of readmissions are potentially avoidable (gov,2012). Leeann N. Comfort, S. M. (2018). Medicare Accountable Care Organizations of Diverse Structures Achieve Comparable Quality and Cost Performance. NCBI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6052017/ This article compares three ACO types; physician-led, integrated, and hybrid in quality, spending and likelihood to achieve savings. Research shows that ACOs that are independent primary care providers tend to save more money than hospital-integrated medical groups. This supports Mr. Jone’s case scenario in that he visited a hospital versus a primary care physician or family practice, which resulted in less attentive care, leaving the hospital responsible for lack of communication. #3. Would it be different if Mr. Jones received instructions for a low-sodium diet but chose to ignore them? Yes, it would be different if Mr. Jones encountered instructions for a low sodium diet and chose to ignore them. With that being stated, if Mr. Jones chose to avoid the discharge instructions that were given to him, he is basically implying that he does not care. In this example, Mr. Jones entered a nursing facility and no one gave him a clear explanation of what a low sodium diet is, and why it was important for him to abide by it. When adapting a low sodium diet, physicians tend to suggest that family members assist their loved ones to ensure compliance and understanding of what is required of them. Also, physicians convey a plan of action technique that best suits the patient to follow. In Mr. Jones’ defense, he probably was unsure of what was happening to him and just took what was given, because of the condition he was in. Tending for elderly patients like Mr. Jones and having a discussion on their well being is critical to have. Nonetheless, having the conversation gives important information to continue healthier decisions to maintain independence or safety. Lennie, T. A., Chung, M. L., & Moser, D. K. (2013, September). What should we tell patients with heart failure about sodium restriction and how should we counsel them? Current heart failure reports. Retrieved April 1, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3774591/ The article relates to this discussion because Mr. Jones was not given any instruction. The article explains the correct ways to handle elderly patients going through congestive heart failure. Being on the low sodium diet, and evidence based solutions that can decrease his risk of becoming hospitalized. It also gives insight on what is commonly recommended for a person in his situation to avoid the rise in fluid and swollen ankles. U.S. Department of Health and Human Services. (n.d.). Talking with older patients about sensitive topics. National Institute on Aging. Retrieved April 1, 2022, from https://www.nia.nih.gov/health/talking-older-patients-about-sensitive-topics This article connects with the discussion, it justified how to communicate with elderly patients without avoiding unnecessary awkwardness. Some techniques used to approach sensitive subjects is to directly console the given situation, as well as having resources for more information or support to patients. In the discussion they failed to present Mr. Jones instructions on how to prevent another heart failure episode. Kalogeropoulos, A. P., Georgiopoulou, V. V., Murphy, R. A., Newman, A. B., Bauer, D. C., Harris, T. B., Yang, Z., Applegate, W. B., & Kritchevsky, S. B. (2015). Dietary sodium content, mortality, and risk for cardiovascular events in older adults. JAMA Internal Medicine, 175(3), 410–419. https://doi.org/10.1001/jamainternmed.2014.6278 This article is in accordance with this discussion because it informs us of the dietary sodium intake in older adults. Taking in too much sodium can lead to major health problems for an older person like cardiovascular disease, or heart failure. With this being said without Mr. Jones knowing any different instructions from his normal day the blame can not be placed on him and what can happen to him if the sodium intake does not improve in any way. References Gholizadeh, M., Janati, A., Delgoshaei, B., Gorji, H. A., & Tourani, S. (2018). Implementation requirements for patient discharge planning in the health system: a qualitative study in Iran. Ethiopian Journal of Health Sciences, 28(2), 157. https://doi.org/10.4314/ ejhs.v28i2.7 Howard-Anderson, J., Busuttil, A., Lonowski, S., Vangala, S., & Afsar-manesh, N. (2016). From discharge to readmission: Understanding the process from the patient perspective. Journal of Hospital Medicine, 11(6), 407–412. https://doi.org/10.1002/jhm.2560 Hospital Readmissions Reduction Program (HRRP) https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment /AcuteInpatientPPS/ReadmissionsReduction-Program Kalogeropoulos, A. P., Georgiopoulou, V. V., Murphy, R. A., Newman, A. B., Bauer, D. C., Harris, T. B., Yang, Z., Applegate, W. B., & Kritchevsky, S. B. (2015). Dietary sodium content, mortality, and risk for cardiovascular events in older adults. JAMA Internal Medicine, 175(3), 410–419. https://doi.org/10.1001/jamainternmed.2014.6278 Kavita K. Patel, J. E. (2015). Accountable Care Organizations. AHA Journals. Leeann N. Comfort, S. M. (2018). Medicare Accountable Care Organizations of Diverse Structures Achieve Comparable Quality and Cost Performance. NCBI. Lennie, T. A., Chung, M. L., & Moser, D. K. (2013, September). What should we tell patients with heart failure about sodium restriction and how should we counsel them? Current heart failure reports. Retrieved April 2, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3774591/ Nowicki, M. (2017). Introduction to the Financial Management of Healthcare Organizations, Seventh Edition (Gateway to Healthcare Management) (7th ed.). Health Administration Press. Smeraglio, A., Heidenreich, P. A., Krishnan, G., Hopkins, J., Chen, J., & Shieh, L. (2019). Patient vs provider perspectives of 30-day hospital readmissions. BMJ Open Quality, 8(1), e000264. https://doi.org/10.1136/bmjoq-2017-000264 U.S. Department of Health and Human Services. (n.d.). Talking with older patients about sensitive topics. National Institute on Aging. Retrieved April 1, 2022, from https://www.nia.nih.gov/health/talking-older-patients-about-sensitive-topics Appendix A HSM 331 Discussion 1 Group 4 Members: Britney Smith Eloisa Velasquez Kendra Scott Alexis Ruffin LaToya Williams Raven Vilo Quatvia Stokes Charia W. 2017 ASSETS Current Assets Cash Temporary investments Receivables, net Inventory Prepaid expenses Total Current assets $ 124 45 3,536 175 32 3,912 2016 $ 280 30 2,860 140 40 3,350 Noncurrent assets Land, plant, and equipment Less accumulated depreciation Plant and equipment, net Long-term investments Other noncurent assets Total noncurrent assets 6,980 1,730 5,250 609 113 5,972 6,580 1,259 5,321 790 109 6,220 Total assets 9,884 9,570 LIABILITIES AND NET ASSETS Current liabilities Accounts payable Notes payable Accrued expenses payable Deferred revenues Estimated third-party adjustments Current portion of long-term debt Total current liabilities $ 302 345 871 10 137 184 1,849 $ 370 335 606 15 224 178 1,728 Noncurrent liabilities Long-term debt, net of current portion 3,600 3,500 Total liabilities 5,449 5,228 NET ASSETS Unrestricted net assets Restricted net assets 3,283 1,152 3,190 1,152 Total net assets 4,435 4,342 Total liabilities and net assets $9,884 $9,570 2017 REVENUES Net patient services revenue Premium revenue on sponsored health plans Other operating revenue Total operating revenue EXPENSES Salaries, wages, and benefits Supplies, drugs, and purchased services Estimated bad debt expense Depreciation expense Interest Total operating expenses OPERATING INCOME NON OPERATING INCOME Investment income EXCESS OF REVENUE OVER EXPENSES CHANGE IN NET ASSETS Add: Unrestricted net assets January 1 Unrestricted net assets December 31 8402 400 440 $9,242 4980 3080 600 471 113 9,244 (2) $95 93 3,190 3,283 2016 8119 0 447 $8,566 4278 2956 500 443 109 8,286 280 $85 365 2,825 3,190 Three steps of financial analysis 1. Establishing facts about the organization. 2. Comparing facts about the organization with similar organizations. 3. Using perspective judgements to make decisions about comparisons made. Accounting Equations Balance Sheet: Assets=Liabilities Net Assets Operations: Assets= Liabilities + Net Assets + (Net Revenue -Expenses) Footnotes Purpose of balance sheet: It reflects the organization financial position, towards the end of the accounting period. Als Purpose of statement of operations: Sums up the organization's revenue in a time frame Operating Indicators Average length of stay: Patients days/ discharge Occupancy rate: Patient days/ 365 * license beds References Nowicki, M. (2022). Introduction to the financial management of Healthcare Organizations (7th ed.). Health Admini and net assets. Group Discussion 3, Module 5 Group 4: Alexis Ruffin, Kendra Scott, Britney Smith, Quatavia Stokes, Eloisa Velasquez, Raven Vilo, Charia Williams, LaToya Williams Department of Nursing and Allied Health, Norfolk State University HSM 331-90: Health Financial Management Dr. Batrina Martin April 03, 2022 #1. Who should be financially responsible for the costs related to Mr. Jones’s latest admission? Gholizadeh, M., Janati, A., Delgoshaei, B., Gorji, H. A., & Tourani, S. (2018). Implementation requirements for patient discharge planning in the health system: a qualitative study in Iran. Ethiopian Journal of Health Sciences, 28(2), 157. https://doi.org/10.4314/ ejhs.v28i2.7 Gholizadeh explains how prior to a patient being discharged, all information should be gathered to discuss with the patient and/or a family member which is why it is a vital piece in the health system flow in many countries. According to the article, successful discharge planning has long been identified as the cornerstone of an effective transition of individuals from a hospital to their home. It also explains how the discharge phase of a hospital stay requires several components, including assessment of a patient's current needs, appropriate anticipation of continuing care needs, and recognition of available resources to meet after-hospital care needs. This article examines how discharge planning promotes the quality of inpatient care and reduces unplanned hospital readmission. Gholizadeh reports on preventing certain readmissions has the potential to improve both the quality of life for patients and the financial well-being of healthcare systems. The author also how improvements in hospital discharge planning can significantly improve health outcomes for patients as they move to the next level of care. Howard-Anderson, J., Busuttil, A., Lonowski, S., Vangala, S., & Afsar-manesh, N. (2016). From discharge to readmission: Understanding the process from the patient perspective. Journal of Hospital Medicine, 11(6), 407–412. https://doi.org/10.1002/ jhm.2560 Howard-Anderson reports that by engaging patients or patients for future interventions, including better symptom management and self-care planning prior to discharge, along with more clarity in discharge instructions, promoting awareness of outpatient resources, and improved alignment of patient and provider attitudes, readmissions could potentially be reduced. Smeraglio, A., Heidenreich, P. A., Krishnan, G., Hopkins, J., Chen, J., & Shieh, L. (2019). Patient vs provider perspectives of 30-day hospital readmissions. BMJ Open Quality, 8(1), e000264. https://doi.org/10.1136/bmjoq-2017-000264 Smeraglio reports since it is the healthcare providers responsibility to provide patients with clear instructions before their discharge, the financial responsibility should not fall on Mr. Jones. The author explains how many readmitted patients often feel that the hospital system contributed to their readmission. Since Mr. Jones was readmitted, he may eventually express the same concerns. Nowicki, M. (2017). Introduction to the Financial Management of Healthcare Organizations, Seventh Edition (Gateway to Healthcare Management) (7th ed.). Health Administration Press. This article supports the idea that because the skilled nursing home had an internal auditor, they should be financially responsible for Mr. Jones’s most recent admission. It was the hospital's job to explain that information because proper discharge instructions have the potential to prevent readmissions and enhance the quality of a patient’s life. #2. Should Medicare, or any insurer, pay for readmissions related to errors in discharge instructions? Due to the lack of communication from the hospital , the hospital should be held accountable for Mr. Jones readmission. In the case study it is stated “ The admitting physician discovered that no one at the hospital or skilled nursing facility explained to Mr. Jones the importance of maintaining a low-sodium diet.” It was the charge nurse/ discharge nurse, case manager, to have noticed that Mr. Jones was not well enough to be discharged. Given 4 days in the hospital for his repeat symptoms, Mr. Jones' assigned physician should have been updated on his condition and discharging him should have not been a consideration. Reimbursement for health services are based on certain criteria, which includes, but not limited to high-quality, cost-effective care. The Accountable Care Organization, ACO, was created in 2007, and “mandates provider accountability” (Nowicki, 2018). As an ACO, health care providers, hospitals, and doctors work together to give high-quality care to Medicare patients, with a goal to avoid repeat services and medical errors. ACOs are to “engage in reliable performance measurement techniques that instill confidence in the quality of care provided” The (Kavita K. Patel, 2015). Hospital Readmissions Reduction Program is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in discharge plans, and in turn reduce avoidable readmissions. Hospital Readmissions Reduction Program (HRRP) https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment /AcuteInpatientPPS/ReadmissionsReduction-Program The program supports the national goal of improving healthcare for Americans by linking payment to the quality of hospital care( gov, 2021). The Affordable Care Act established the hospital Readmission Reduction Program in 2012. Under this program hospitals are financially penalized if they have higher than expected risk-standardized 30-day readmission rates for acute myocardial infarction,heart failure , and pneumonia. Hospitals readmission measures have been touted not only as a quality measure, but also as a means to bend the healthcare cost curve( gov,2012). Hospital readmissions are associated with favorable patient outcomes and high financial costs (gov,2012). The Medicare Payment Advisory Commission has estimated that 12% of readmissions are potentially avoidable (gov,2012). Leeann N. Comfort, S. M. (2018). Medicare Accountable Care Organizations of Diverse Structures Achieve Comparable Quality and Cost Performance. NCBI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6052017/ This article compares three ACO types; physician-led, integrated, and hybrid in quality, spending and likelihood to achieve savings. Research shows that ACOs that are independent primary care providers tend to save more money than hospital-integrated medical groups. This supports Mr. Jone’s case scenario in that he visited a hospital versus a primary care physician or family practice, which resulted in less attentive care, leaving the hospital responsible for lack of communication. #3. Would it be different if Mr. Jones received instructions for a low-sodium diet but chose to ignore them? Yes, it would be different if Mr. Jones encountered instructions for a low sodium diet and chose to ignore them. With that being stated, if Mr. Jones chose to avoid the discharge instructions that were given to him, he is basically implying that he does not care. In this example, Mr. Jones entered a nursing facility and no one gave him a clear explanation of what a low sodium diet is, and why it was important for him to abide by it. When adapting a low sodium diet, physicians tend to suggest that family members assist their loved ones to ensure compliance and understanding of what is required of them. Also, physicians convey a plan of action technique that best suits the patient to follow. In Mr. Jones’ defense, he probably was unsure of what was happening to him and just took what was given, because of the condition he was in. Tending for elderly patients like Mr. Jones and having a discussion on their well being is critical to have. Nonetheless, having the conversation gives important information to continue healthier decisions to maintain independence or safety. Lennie, T. A., Chung, M. L., & Moser, D. K. (2013, September). What should we tell patients with heart failure about sodium restriction and how should we counsel them? Current heart failure reports. Retrieved April 1, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3774591/ The article relates to this discussion because Mr. Jones was not given any instruction. The article explains the correct ways to handle elderly patients going through congestive heart failure. Being on the low sodium diet, and evidence based solutions that can decrease his risk of becoming hospitalized. It also gives insight on what is commonly recommended for a person in his situation to avoid the rise in fluid and swollen ankles. U.S. Department of Health and Human Services. (n.d.). Talking with older patients about sensitive topics. National Institute on Aging. Retrieved April 1, 2022, from https://www.nia.nih.gov/health/talking-older-patients-about-sensitive-topics This article connects with the discussion, it justified how to communicate with elderly patients without avoiding unnecessary awkwardness. Some techniques used to approach sensitive subjects is to directly console the given situation, as well as having resources for more information or support to patients. In the discussion they failed to present Mr. Jones instructions on how to prevent another heart failure episode. Kalogeropoulos, A. P., Georgiopoulou, V. V., Murphy, R. A., Newman, A. B., Bauer, D. C., Harris, T. B., Yang, Z., Applegate, W. B., & Kritchevsky, S. B. (2015). Dietary sodium content, mortality, and risk for cardiovascular events in older adults. JAMA Internal Medicine, 175(3), 410–419. https://doi.org/10.1001/jamainternmed.2014.6278 This article is in accordance with this discussion because it informs us of the dietary sodium intake in older adults. Taking in too much sodium can lead to major health problems for an older person like cardiovascular disease, or heart failure. With this being said without Mr. Jones knowing any different instructions from his normal day the blame can not be placed on him and what can happen to him if the sodium intake does not improve in any way. References Gholizadeh, M., Janati, A., Delgoshaei, B., Gorji, H. A., & Tourani, S. (2018). Implementation requirements for patient discharge planning in the health system: a qualitative study in Iran. Ethiopian Journal of Health Sciences, 28(2), 157. https://doi.org/10.4314/ ejhs.v28i2.7 Howard-Anderson, J., Busuttil, A., Lonowski, S., Vangala, S., & Afsar-manesh, N. (2016). From discharge to readmission: Understanding the process from the patient perspective. Journal of Hospital Medicine, 11(6), 407–412. https://doi.org/10.1002/jhm.2560 Hospital Readmissions Reduction Program (HRRP) https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment /AcuteInpatientPPS/ReadmissionsReduction-Program Kalogeropoulos, A. P., Georgiopoulou, V. V., Murphy, R. A., Newman, A. B., Bauer, D. C., Harris, T. B., Yang, Z., Applegate, W. B., & Kritchevsky, S. B. (2015). Dietary sodium content, mortality, and risk for cardiovascular events in older adults. JAMA Internal Medicine, 175(3), 410–419. https://doi.org/10.1001/jamainternmed.2014.6278 Kavita K. Patel, J. E. (2015). Accountable Care Organizations. AHA Journals. Leeann N. Comfort, S. M. (2018). Medicare Accountable Care Organizations of Diverse Structures Achieve Comparable Quality and Cost Performance. NCBI. Lennie, T. A., Chung, M. L., & Moser, D. K. (2013, September). What should we tell patients with heart failure about sodium restriction and how should we counsel them? Current heart failure reports. Retrieved April 2, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3774591/ Nowicki, M. (2017). Introduction to the Financial Management of Healthcare Organizations, Seventh Edition (Gateway to Healthcare Management) (7th ed.). Health Administration Press. Smeraglio, A., Heidenreich, P. A., Krishnan, G., Hopkins, J., Chen, J., & Shieh, L. (2019). Patient vs provider perspectives of 30-day hospital readmissions. BMJ Open Quality, 8(1), e000264. https://doi.org/10.1136/bmjoq-2017-000264 U.S. Department of Health and Human Services. (n.d.). Talking with older patients about sensitive topics. National Institute on Aging. Retrieved April 1, 2022, from https://www.nia.nih.gov/health/talking-older-patients-about-sensitive-topics Appendix A 
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