The recent CMS discharge planning rule that went into effect in November 2019 included several changes aimed at improving care transitions and encouraging patients’ involvement in their follow-up treatment and care protocols. (Click here to review the rule in the Federal Register.) With those rules in place, it is now imperative for organizations to familiarize themselves with and meet the latest requirements to participate in Medicare and Medicaid programs. To ensure compliance, organizations should evaluate existing discharge processes, incorporate patients’ goals of care into discharge planning, and share necessary medical information with any receiving providers.
Efficient discharge processes are critical to ensure patients’ safe transition from hospitals to their homes or post-acute care facilities. Poor discharge planning can result in increased patient readmissions and reduced safety, which hurts the cost involved in care delivery and the patient experience within health systems.
This rule impacts discharge planning requirements in various healthcare settings:
- Hospitals including short-term acute care hospitals, long-term care hospitals, rehabilitation hospitals, psychiatric hospitals, children’s hospitals, and cancer hospitals
- Critical access hospitals
- Home health agencies
The objective of this regulation is to provide better care coordination, promote transparency by improving patients’ access to data, and provide vital information to patients to empower them to make informed decisions regarding their care.
3 Key Areas to Review for Compliance
While this rule might bring about extensive changes to some organizations’ existing discharge planning processes, there are three areas in particular that all applicable facilities should review to make sure they are compliant and delivering care that is best for the patient:
- Improving Patient Access to Medical Records: The regulation states that patients have a right to access their medical records and instruct hospitals to provide these records in whatever format patients prefer, as long as the format can be produced by the organization. For example, if a patient requests information in an electronic format and the hospital maintains records electronically, then the information should be easy to produce and share in the requested format. This provision is meant to encourage hospitals not to frustrate a patient’s legitimate effort to gain access to their medical record.
- Providing Information on Post-Acute Care Facilities and Providers: Hospitals are expected to be more involved in a patient’s post-acute care by discussing it with patients and providing a list of potential post-acute care facilities and providers for their post-discharge care. Providers must share relevant quality performance data from the recommended post-acute care facilities, including but not limited to metrics like the number of pressure ulcers at the facility, incidence of falls leading to injury, and readmission rates, to ensure patients make informed decisions regarding their post-discharge care. The data shared should also be relevant to the patient’s goals of care and treatment preferences, and all the interactions regarding post-acute care must be documented in patients’ medical records for future reference.
- Creating Discharge Plans and Discharge Information: A discharge plan must be created for patients at risk for adverse events at an early stage of hospitalization, with a focus on their goals of care and treatment preferences. Patients should be active participants during the entire planning process, and the results of the discharge evaluations carried out by the providers must be regularly shared with patients to ensure their continuous involvement.
Patient discharge information must be provided to patients and the post-acute care facilities or providers at the time of discharge or transfer to ensure a safe and successful care transition. Discharge summaries, which include the information required for the effective management of a patient’s condition post-discharge, must be completed before their first follow-up visit to ensure a continuation in treatment and care protocols.
Discharge Planning Best Practices
As a community of over 1,900 hospitals, HBI is in contact with providers across the country daily. Discharge planning and care transitions are perennial topics of interest for HBI members. During our research, leaders at better-performing organizations often share insights on best practices, and in many cases provide tools their fellow providers can refer to or adopt. One organization shared the discharge planning tool it uses for patients that are transitioning from the hospital to post-acute care, such as a rehab or skilled nursing facility.