The Centers for Medicare & Medicaid Services has revised the State Operations Manual’s Hospital Appendix to clarify the discharge planning requirements for hospitals, including when discharging patients to skilled nursing facilities, rehabilitation centers, home health agencies and other post-acute service centers.
Hospitals must have discharge planning processes in place for all inpatients, including:
- Screening all inpatients to determine which ones are at risk of adverse health consequences post-discharge if they lack discharge planning;
- Evaluation of the post-discharge needs of inpatients identified in the first stage, or of inpatients who request an evaluation, or whose physician requests one;
- Development of a discharge plan if indicated by the evaluation or at the request of the patient’s physician; and
- Initiation of the implementation of the discharge plan prior to the discharge of an inpatient.
Although it not a requirement, hospitals are “encouraged to obtain input from: healthcare facilities and professionals who provide care to discharged patients, including but not limited to: nursing homes/skilled nursing facilities, home health agencies, primary care physicians and clinics, etc.”
The revisions also emphasize the importance of better communication and care transitions in reducing hospital readmissions. “While hospitals are not solely responsible for the success of their patients’ post-hospital care transitions, under the discharge planning CoP hospitals are expected to employ a discharge planning process that improves the quality of care for patients and reduces the chances of readmission,” the revised manual states. Recent research published in JAMA Internal Medicine indicates that predicting patient risk and including it in discharge planning can reduce 30-day readmissions.
The manual revisions also create documentation policies to handle inpatients who refuse to participate discharge planning.