You may be more aware of the option to discharge versus not discharge, but like most home health agencies, you continue to be challenged with actually making that decision. It would be easier if there was a hard-and-fast rule, and you wouldn’t have to think about it. Instead, you must weigh pros and cons on an individual patient basis. There just isn’t one set formula.
According to a question posed to CMS, many home health agencies commonly complete a transfer and then ROC for patients transferred to any inpatient setting, unless they are not expected to need further home care. The questioner wanted guidance about how to answer M0100 (Reason for assessment (RFA)).
When to transfer vs. discharge:
CMS states that there is no change in the OASIS guidance. Agencies should use M0100 responses 6 and 7 when a home health patient is admitted for an inpatient stay just as before:
- In the event that a patient had a qualifying hospital admission and was expected to return to your agency, you would complete RFA “6 — Transferred to an inpatient facility — patient not discharged from agency.”
- If the patient was not expected to return to your agency after this inpatient hospital stay, you would complete RFA “7 — Transfer to an inpatient facility — patient discharged from agency.”
- If a patient requires post-acute care in a SNF, IRF, LTCH or IPF during the 30-day period of home health care, CMS expects and recommends your home health agency discharge the patient by completing the RFA-7. Your agency must readmit the patient with a new start-of-care assessment upon return to home care.
- If your agency decides to complete an RFA-6, you must complete an RFA-3 (Resumption of care) when the patient returns to home care.
This was just one of several answers provided by CMS in their April quarterly Q&As published to the CMS website April 21, 2020.