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CMS Proposes New Discharge Planning Rule with Eye Toward Thoroughness, Patient Preferences and Followup

Posted on November 10, 2015   |   
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CMS Discharge Plan Rule

In an effort to improve post-discharge care for patients and reduce preventable readmissions, CMS published a new proposed rule that would strengthen the discharge planning requirements for hospitals participating in Medicare and Medicaid. This would include long-term care and inpatient rehabilitation facilities, critical access hospitals and home health agencies.

The proposed rule calls upon these organizations and their providers to increase the involvement of patients and their families in the discharge planning process. For all patients, CMS asks that providers and hospitals become increasingly aware and connected to community supports and services that can improve health outcomes for their patients. The rule suggests that initial contact and coordination is insufficient in maintaining long-term outcomes, and asks that all parties remain in coordinated communication well after post-discharge discussions have taken place.

The proposed rule identifies several issues with the current state of overall discharge planning practices:

  • Approaches are inconsistent between organizations and differ substantially in the degree to which addressed variables meet patient need
  • Patient education is often passive and insufficient (e.g., simply giving patients and family members literature to read upon returning home)
  • Confusion among healthcare providers and administrators as to what level of discharge planning implementation is required by CMS

To address these issues, new requirements for discharge from some facilities include:

  • Organizations would be required to engaging in a team-based effort in designing a discharge process appropriate to their organization;
  • Patients and caregivers would be of central importance on this team and discharge plans would be designed with their input, to include a patient’s preferences for goals and treatment (including supporting a patient in a data-driven decision making process for considering post-acute care options)
  • A written discharge plan would be required for all inpatients and some outpatients (e.g., patients in observation status, emergency department patients who a healthcare provider determines need a discharge plan).
  • Early in a hospital stay, the care team would develop a discharge plan incorporating patient goals, preferences and needs. For those stays longer than 24 hours, CMS would require that this process begin within 24 hours of inpatient admission or outpatient registration.
  • Given the evolving nature of a specific patient’s presentation and care, the rule would require that the discharge planning process encourage regular re-evaluation and updating, if necessary.
  • The healthcare provider principally responsible for a patient’s care during their stay would be required to participate in discharge planning for that patient.
  • A registered nurse, social worker or other personnel qualified in accordance with the hospital’s discharge planning policy would ultimately be responsible for overseeing the development of the discharge plan.
  • The discharge plan would include a discussion of the caregiving and community support available to that patient; the capability of a patient or caregiver in providing care post-discharge; consideration of a variety of tools available to maximizing patient outcomes, including telehealth, assistive technologies and meal services; all appropriate community supports of a non-health care nature, including transportation, housing and ongoing supports such as centers for independent living and aging and disability resource centers; and relevant medications.
  • In addition, essential patient factors – including primary diagnosis and relevant comorbidities, readmissions risk, communication needs and psychosocial history – would be required in developing and implementing the discharge plan.
  • Discharge plans would be provided to the patient, appropriate caregivers and any other involved practitioners in the most appropriate format available. Providers would be required to confirm patient and caregiver understanding of the discharge plan’s details.
  • Medication reconciliation would take place prior to discharge and would include patients as an integral part of the process.
  • Providers would work beyond discharge to ensure all members of the treatment team – including those practitioners involved in follow-up care – would receive all materials and support necessary to provide comprehensive care.

The rule also specifically asks these facilities to improve these services for patients with behavioral health issues, included those with substance abuse disorders. Within this specific patient subgroup, CMS calls for organizations to:

  • Identify before discharge what services will be needed post-discharge, including tele-behavioral health, if appropriate
  • Identify local organizations offering community services and develop or strengthen existing partnerships with these organizations to develop and implement a psychiatric discharge plan specific to the patient
  • Work with the patient in making appropriate referrals for post-acute behavioral health care, including ensuring appropriate medical information is communicated to the referred healthcare provider(s)

Legislative authority to modify these requirements was granted under the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act).

For the history of the proposed rule, details on all requirements by type of organization (i.e., hospital, home health agency, critical access hospital), reporting requirements, lists of relevant resources and the accompanying regulatory impact analysis, please consult the CMS press release and Federal Register publication https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-10-29.html.

Comments can be made to regulations.gov and are due by January 4, 2016 at 11:59 PM EST. https://www.federalregister.gov/articles/2015/11/03/2015-27840/medicare-and-medicaid-programs-revisions-to-requirements-for-discharge-planning-for-hospitals#open-comment

How do you think this will impact patient care?

1 Comments



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  • It seems that with the additional discharge requirements, there will be an increase in multi-disciplinary type transitions of care that will take place. I think this is a benefit to not only patients (receiving higher quality care) but also to providers (namely physicians) as there can be more ownership of the discharge care due to a financial incentive to make sure these patients get the care they need to reduce preventable readmissions.
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