CMSA Today - Issue 5, 2016 - 25
CMS Proposes Major Changes in
Discharge Planning for Hospitals
BY ELIZABETH E. HOGUE, ESQ
n Nov. 3, 2015, the Centers for Medicare
& Medicaid Services (CMS) published
proposed regulations governing
discharge planning by hospitals in the Federal
Register. If finalized, these proposed regulations
will require hospitals to devote considerably
more time and resources to discharge planning
activities. Comments to these proposed
regulations are due sixty days from the date
of publication in the Federal Register.
In addition to the requirements described
in Parts 1, 2 and 3 of this series (published in
Issue 1, 2016 of CMSA Today™), if proposed
regulations are finalized as drafted, hospitals
will also be required to engage in the activities
For patients who are discharged to home
and referred for home health agency (HHA)
services or transferred to a skilled nursing
facility (SNF), inpatient rehab facility (IRF)
or long-term care hospital (LTCH) additional
requirements must be met as follows:
Hospitals must include a list of HHAs, SNFs, IRFs
and LTCHs in patients' discharge plans that:
* Are available to discharged patients.
* Participate in the Medicare Program.
* HHAs that serve the geographic area in
which the patient resides and SNFs, IRFs and
LTCHs that are located in geographic areas
requested by patients.
Lists must be presented to patients for whom
home health care, SNF, IRF or LTCH services are
indicated and appropriate as determined by
discharge planning evaluations.
Hospitals must make patients enrolled in
managed care organizations (MCOs) aware
of the need to verify with their MCOs
which providers are in network. If hospitals
have such information, it must be shared
Hospitals must document in patients' medical
records that lists were presented to patients or
As part of the discharge planning process,
hospitals must inform patients or patients'
representatives of their freedom to choose
among participating Medicare providers of
post-discharge services and must respect
patients' or their representatives' goals of
care and treatment preferences, along with
any other preferences they express.
Hospitals may not specify or otherwise limit
the qualified providers or suppliers that are
available to patients.
Discharge plans must also identify HHAs or SNFs
to which patients are referred in which hospitals
have disclosable financial interests or vice versa.
Disclosable financial interests are determined
consistent with 42 CFR 420, Subpart C.
The above proposed regulations make it clear
that hospitals will be required to present lists of
IRFs and LTCHs in addition to HHAs and SNFs, if
they are not already doing so.
If proposed regulations are finalized as
drafted, CAHs will be required to meet the
specific requirements regarding discharge
planning described below.
CAHs will be required to develop and
implement effective discharge planning
processes that focus on preparing patients to
participate in post-discharge care, planning
for post-discharge care that is consistent
with patients' goals for care and treatment
preferences, effective transition of patients from
CAHs to post-discharge care and reduction of
factors leading to preventable readmissions to
CAHs or hospitals.
According to the proposed regulations,
policies and procedures governing discharge
planning must be:
* Developed with input from CAHs' professional
healthcare staff and nursing leadership as well
as other relevant departments.
* Reviewed and approved by the governing
body or responsible individual.
* Reduced to writing.
CAHs' discharge planning processes must
also ensure that discharge goals, preferences
and needs of individual patients are identified
and result in development of discharge plans
for each patient using the following processes:
Coordination of evaluations of discharge
needs and development of discharge plans
by registered nurses, social workers or other
personnel qualified in accordance with CAHs'
discharge planning policies.
Identification of anticipated goals, preferences
and discharge needs for patients' within 24
hours after admission or registration.
Completion of discharge planning processes
prior to discharge home or transfer to
another facility without delays in discharges
Identification of discharge needs and
completion of discharge planning processes
for patients who stay less than 24 hours.
Regular re-evaluation of patients to identify
changes that require modification of discharge
plans and updates of discharge plans to reflect
Involvement of practitioners responsible for
the care of patients in ongoing processes
of establishing patients' goals of care
and treatment preferences that inform
Identification of caregiver/support persons
and community-based care availability and
patients' or caregivers' support persons
capabilities to perform required care;
including self-care, care from support
person(s), follow-up care from community
based providers, care from post-acute
facilities or, in the case of patients admitted
from long-term care or other residential
facilities, care in that setting, as part of
identification of discharge needs.
Consideration admitting diagnoses or reason
for registration, admitting diagnoses or reason
for registration, relevant co-morbidities and
past medical and surgical history, anticipated
ongoing care needs post-discharge,
Issue 5 * 2016 * DIGITAL
Table of Contents for the Digital Edition of CMSA Today - Issue 5, 2016
President's Letter: Leading Through Change
Immediate Past President's Letter: Risks, Challenges and Progress
CMSA Corporate Partners
Normalizing End-of-Life Care with Rich Conversations
Personal Feelings/Professional Face: The Hidden Grief of the Helping Professional
INDEX OF ADVERTISERS
CMSA Today - Issue 5, 2016 - cover1
CMSA Today - Issue 5, 2016 - cover2
CMSA Today - Issue 5, 2016 - 3
CMSA Today - Issue 5, 2016 - 4
CMSA Today - Issue 5, 2016 - 5
CMSA Today - Issue 5, 2016 - President's Letter: Leading Through Change
CMSA Today - Issue 5, 2016 - 7
CMSA Today - Issue 5, 2016 - 8
CMSA Today - Issue 5, 2016 - Immediate Past President's Letter: Risks, Challenges and Progress
CMSA Today - Issue 5, 2016 - 10
CMSA Today - Issue 5, 2016 - 11
CMSA Today - Issue 5, 2016 - Association News
CMSA Today - Issue 5, 2016 - 13
CMSA Today - Issue 5, 2016 - CMSA Corporate Partners
CMSA Today - Issue 5, 2016 - 15
CMSA Today - Issue 5, 2016 - Normalizing End-of-Life Care with Rich Conversations
CMSA Today - Issue 5, 2016 - 17
CMSA Today - Issue 5, 2016 - 18
CMSA Today - Issue 5, 2016 - 19
CMSA Today - Issue 5, 2016 - 20
CMSA Today - Issue 5, 2016 - 21
CMSA Today - Issue 5, 2016 - Personal Feelings/Professional Face: The Hidden Grief of the Helping Professional
CMSA Today - Issue 5, 2016 - 23
CMSA Today - Issue 5, 2016 - 24
CMSA Today - Issue 5, 2016 - 25
CMSA Today - Issue 5, 2016 - 26
CMSA Today - Issue 5, 2016 - INDEX OF ADVERTISERS
CMSA Today - Issue 5, 2016 - 28
CMSA Today - Issue 5, 2016 - cover3
CMSA Today - Issue 5, 2016 - cover4