CMSA Today - Issue 5, 2016 - 26

readmission risks, relevant psychosocial history, communication needs, including language barriers, diminished eyesight and hearing and self-reported literacy of patients, patients' representatives or caregiver/support person(s), as applicable, patients' access to non-healthcare services and communitybased providers, and patients' goals and preferences when evaluating patients. Involvement of patients and caregiver/ support persons in development of discharge plans, including informing them of final plans to prepare them for post-discharge care. Inclusion of patients' goals of care and treatment preferences. Assistance to patients, their families and their caregivers/support persons to select a postacute care provider by using and sharing data that includes but is not limited to home health agency (HHA), skilled nursing facility (SNF), independent rehab facility (IRF) or long-term care hospital (LTCH) data on quality measures and data on resources use measures. Data on quality measures and data on resources use measures furnished to patients must be specific to post-acute care setting(s) and relevant and applicable to patients' goals of care and treatment preferences. Evaluation of patients' discharge needs and discharge plans must be documented and completed on a timely basis and based on patients' goals, preferences, strengths and needs, so that appropriate arrangements for post-CAH care are made before discharge to avoid unnecessary delays in discharge. Inclusion of discharge plans in patients' medical records and discussion of results of evaluations with patients or their representatives. Assessments of discharge planning processes, including continuous, periodic review of a representative sample of discharge plans, especially with patients who were readmitted within 30 days of previous admissions, to ensure that plans are responsive to patients' post-discharge needs. If proposed regulations are finalized as drafted, discharge planning at CAHs will become a tall order indeed! PART 6 If proposed regulations are finalized as drafted, CAHs will be required to meet specific requirements regarding discharge planning described below, in addition to the 26 CMSA TODAY requirements summarized in Part 5 of this article series. CAHs will be required to provide discharge instructions at the time of discharge to: * Patients and/or patients' caregiver/support persons. * Post-acute care service providers or suppliers, if patients are referred to community-based services. Discharge instructions provided by CAHs must include, but are not necessarily limited to, the following: Instructions on post-discharge care to be used by patients or their caregivers/support person(s) in patients' homes, as identified in discharge plans. Written information on warning signs and symptoms that may indicate the need for immediate medical attention. This information must include written instructions on what patients or caregiver(s)/support person(s) should do and who they should contact if warning signs or symptoms are present. Prescriptions for medications that are required after discharge, including a list of names, indications and dosages of each drug along with any significant risks and side effects of each drug as appropriate to each patient. Reconciliation of all discharge medications with patients' pre-CAH admission/ registration medications, both prescribed and over-the-counter. Written instructions regarding patients' follow-up care, appointments, pending and/or planned diagnostic tests and pertinent contact information, including telephone numbers, for practitioners involved in follow-up care for any providers/suppliers to whom patients have been referred for follow-up care. CAHs will also be required to send the following information to practitioners responsible for follow up care: * Copies of discharge instructions and discharge summaries within 48 hours of patients' discharges. * Pending test results within 24 hours of their availability. CAHs will also be required to establish a post-discharge follow-up process. When patients are transferred from CAHs to other healthcare facilities, CAHs will be required to send necessary medical information to receiving facilities at the time of transfer. Necessary medical information includes: Issue 5 * 2016 * DIGITAL * Demographic information, including but not limited to name, sex, date of birth, race, ethnicit, and preferred language * Contact information for the practitioner responsible for the care of patients * Advance directive, if any * Course of illness/treatment * Procedures * Diagnoses * Laboratory tests and results of pertinent laboratory and other diagnostic testing * Consultation results * Functional status assessment * Psychosocial assessments, including cognitive status * Social supports * Behavioral health issues * Reconciliation of all discharge medications with patients' pre-CAH admission/ registration medications both prescribed and over-the-counter * All known allergies, including allergies to medications * Immunizations * Smoking status * Vital signs * Unique device identifier(s) for patients' implantable devices, if any * All special instructions or precautions for ongoing care, as appropriate * Patients' goals and treatment preferences * Any other necessary information, including copies of patients' discharge instructions, discharge summaries and any other documentation as applicable to ensure safe and effective transitions of care that support post-discharge goals for patients. It seems unlikely that CMS will make substantial changes in these regulations when they are finalized. Discharge planners/ case managers, now is the time to start getting ready! ■ Elizabeth E. Hogue is an attorney in private practice with extensive experience in health care. She represents clients all over the country including professional associations, managed care providers, and health care providers including hospitals, long-term care facilities, home health agencies, durable medical equipment companies, and hospices. She can be reached at ElizabethHogue@ ElizabethHogue.net. ©2016 ELIZABETH E. HOGUE, ESQ. REPRINTED WITH PERMISSION.

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
Association News
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
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http://www.nxtbook.com/naylor/CMSQ/CMSQ0413
http://www.nxtbook.com/naylor/CMSQ/CMSQ1413
http://www.nxtbook.com/naylor/CMSQ/CMSQ0313
http://www.nxtbook.com/naylor/CMSQ/CMSQ1313
http://www.nxtbook.com/naylor/CMSQ/CMSQ0213
http://www.nxtbook.com/naylor/CMSQ/CMSQ1213
http://www.nxtbook.com/naylor/CMSQ/CMSQ0113
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http://www.nxtbook.com/nxtbooks/naylor/CMSQ0412
http://www.nxtbook.com/nxtbooks/naylor/CMSQ1412
http://www.nxtbook.com/nxtbooks/naylor/CMSQ0312
http://www.nxtbook.com/nxtbooks/naylor/CMSQ1312
http://www.nxtbook.com/nxtbooks/naylor/CMSQ0212
http://www.nxtbook.com/nxtbooks/naylor/CMSQ1212
http://www.nxtbook.com/nxtbooks/naylor/CMSQ0112
http://www.nxtbook.com/nxtbooks/naylor/CMSQ1112
http://www.nxtbook.com/nxtbooks/naylor/CMSQ0411
http://www.nxtbook.com/nxtbooks/naylor/CMSQ1411
http://www.nxtbook.com/nxtbooks/naylor/CMSQ0311
http://www.nxtbook.com/nxtbooks/naylor/CMSQ1311
http://www.nxtbook.com/nxtbooks/naylor/CMSQ0211
http://www.nxtbook.com/nxtbooks/naylor/CMSQ1211
http://www.nxtbook.com/nxtbooks/naylor/CMSQ0111
http://www.nxtbook.com/nxtbooks/naylor/CMSQ1111
http://www.nxtbookMEDIA.com