Executive Summary

The Centers for Medicare & Medicaid Services has issued proposed changes to the Medicare Conditions of Participation that would increase the focus on patient preferences in the discharge process and beef up communication when patients are discharged from the hospital.

• The requirements would be in effect for critical access hospitals, long-term acute care hospitals, and inpatient rehabilitation hospitals in addition to acute care hospitals and would require a discharge plan for patients receiving observation services, patients being released from the emergency department, and patients receiving same-day surgery or procedures that require anesthesia or sedation.

• The proposed rule requires the discharge plan to include patients’ goals and preferences and that the treating physician help create the plan. It includes specific requirements for discharge instructions.

• A big focus is providing the primary care physician with the discharge summary and other comprehensive information to the patient’s primary care physician within 48 hours of discharge and pending test results within 24 hours of their availability. It spells out specific information that should be provided at the time a patient transfers to a post-acute facility or is referred for home health services.


Hospitals may have to make major changes in their discharge planning process if the Centers for Medicare & Medicaid Services (CMS) enacts a proposed rule beefing up the discharge planning requirements in the Medicare Conditions of Participation (CoPs).

Hospitals have to comply with the Conditions of Participation or they could be fined or lose their ability to bill for Medicare and Medicaid.

The proposed rule was issued Nov. 3, 2015, with the period for comments from stakeholders ending Jan. 3. According to Sue Dill Calloway, RN, MSN, JD, CPHRM, CCM, CCP, president of Patient Safety Education and Consulting in Dublin, OH, Mary Ellen Palowich, EMTALA technical lead and hospital analyst for CMS, predicts that the final rule will likely be published in February.

“The proposed rule reinforces what CMS has recommended in the past to improve the discharge process and reinforces the importance of case managers in a hospital,” says Jackie Birmingham, RN, BSN, MS, CMAC, vice president emerita of clinical leadership for Curaspan, a Newton, MA-based consulting firm.

The rule expands the patient population included in the discharge planning requirements to include patients being discharged from critical access hospitals, long-term acute care hospitals, and inpatient rehabilitation hospitals. In addition, it requires that case managers or social workers create a discharge plan for patients receiving observation services, patients in the emergency department, and those receiving same-day surgery or procedures that require anesthesia or sedation.

The proposal includes similar discharge planning rules for critical access hospitals and proposed rules that home health agencies must follow when they discharge patients.

CMS rewrote the discharge planning standards in 2013 and in November 2014 published the discharge planning worksheet for state and federal surveyors to use when they assess hospitals’ compliance with the Medicare CoPs, Dill Calloway says. Many of the requirements in the proposed rule were included as suggestions in the worksheet’s advisory boxes, she adds. CMS will have to rewrite the discharge planning worksheet to reflect the changes when they are final, Dill Calloway says.

CMS mandated the changes to address some of the biggest gaps in readmission prevention and patient transitions, adds Larry Magras, MD, MBA, FACPE, senior director at Huron Consulting, a Chicago-based healthcare consulting firm.

CMS is definitely focusing on readmissions, including preventing readmissions by patients receiving observation services, emergency department patients, and outpatient surgery, he adds.

The proposed regulations were also written to implement the discharge planning requirements of the Improving Medicare Post-Acute Transformation Act of 2014 (IMPACT), which requires home health agencies, skilled nursing facilities, long-term acute care hospitals, and inpatient rehabilitation facilities to submit standardized data, including quality measures, resource use, and other measures, Dill Calloway says. (For details on the IMPACT Act, see the December 2015 issue of Hospital Case Management.) Many of the requirements of the act are being addressed in separate rules, Dill Calloway says.

The proposed rule requires hospitals to develop a discharge planning process that includes patients’ goals and preferences in the discharge plan, prepares patients and their caregivers to follow the patient’s discharge plan, provides a smooth transition to post-acute care, and, in the process, reduces readmissions, Birmingham says. The proposal also calls for hospitals to assess the discharge planning process on a regular basis and review the cases of patients who were readmitted within 30 days, looking for ways that discharge planning and patient transitions can be improved.

“The proposed regulations are solidifying what the more progressive institutions have already built: a robust discharge process for all patients and a focus on preventing readmissions,” says Donna Turtle, FACHE, MPH, RN, director at Huron Consulting. Hospitals may have to make changes in how they provide discharge planning in order to comply with the proposed regulations, she adds.

She advises hospitals to review their discharge planning process in its entirety and ensure that what they are doing meets the needs of patients and includes all goods and services the patient will need after discharge.

Hospitals should revise their discharge policy to include the new requirements and make the entire staff aware of it, Dill Calloway says.

The proposed regulations require hospitals to get input from the medical and nursing staff, along with other relevant staff such as social workers and discharge planners, when they develop the discharge planning policy. The policy must be in writing and must be approved by the hospital board.

“Hospitals also may want to consider redrafting the discharge planning evaluation to include the CMS requirements,” Dill Calloway says. (For details on what the discharge evaluation must include, see box in this issue.)

The rule requires hospitals to identify potential discharge needs for every patient within 24 hours of admission and complete the process before the patient is discharged or transferred to another facility. If a patient stays less than 24 hours, the discharge planner still must identify the patient’s needs and complete the discharge planning process and not delay the discharge or transfer.

The regulations state that the discharge evaluation must be coordinated by a qualified person such as an RN or a social worker, Dill Calloway adds.

Hospital staff tend to think that responsibility for a discharge planning assessment belongs only to case management, but that’s not true, Birmingham says. “Assessing for admission criteria and utilization review are also assessments,” she says.

Collaboration between case managers and the nursing staff is going to be critical in order to meet the requirement to perform a discharge planning assessment within 24 hours of admission, Birmingham says.

“Nursing typically has delegated anything to do with discharge planning to the case managers, yet staff nurses perform the admission assessment and find out more about the patients than anybody else. Hospitals need to ensure that discharge planning assessment is part of the job description for staff nurses,” Birmingham says.

Under the new regulations, case managers no longer will be able to just develop a discharge plan and present it to patients, says Kathy Jermain, RN, BSHM, IQCI, director with Huron Consulting.

“Now, CMS is proposing that they involve the patient and the entire hospital team in the discharge planning process. A big focus is engaging the patient and family in actual discharge planning. The proposal requires discharge planners to consider the patient’s and caregiver’s ability to perform the care needed after discharge, and include the patient’s goals and preferences in developing a discharge plan,” Jermain says.

The rule also emphasizes that treating physicians should be involved in developing the discharge plan, rather than the more typical practice when the case manager creates the plan and the physician signs off on it, Birmingham says.

Dill Calloway suggests that a good way to comply with the rule is for an interdisciplinary committee to be involved in the discharge planning process, especially for a high-risk patient, such as one who just had a major stroke. The committee should include the attending physician, the rest of the clinical staff providing care, and the patient’s support person, she says.

The new emphasis on transitions and preventing readmissions means that hospitals should perform an admission assessment and a discharge evaluation on every patient, Turtle says.

“We are at a point in healthcare now where the acuity of patients being discharged from inpatient facilities has risen. We should assume that all patients are going to need discharge planning unless it’s ruled out,” Turtle says.

A good discharge plan should be a blend of the patient’s clinical and psychosocial needs along with financial issues, Turtle says. “It works well for the case managers to lead the discharge planning and determine what skill sets are needed to complete the plan and then involve social work if the patient has psychosocial or financial needs,” she says.

The rule also requires patients to be re-evaluated for discharge needs throughout the stay and that the plan be revised to reflect any changes in patients’ conditions or needs, Dill Calloway says.

In recent years, a best practice has been for case managers to see every patient and complete a discharge evaluation plan, then review the record every day to see if there are changes, she says, recommending that all hospitals should adopt the practice.

“Most discharges aren’t complicated, but case managers need to know what is happening with patients and adjust the discharge plan accordingly. If case managers don’t see the patients every day, they have to rely on nurses for information on any changes and the nurses are busy doing their own jobs and may not inform the case managers of the changes,” Dill Calloway adds.

For instance, a patient who has uncomplicated surgery could develop deep venous thrombosis and have an anticoagulant prescribed. The patient would need a consultation from a pharmacist and a dietician as well as follow-up visits to an anticoagulant clinic, she says. Or, a patient could fall and need a wheelchair after discharge. “If case managers don’t monitor the changes, they could overlook a discharge need that would result in a readmission,” she says.

The rule makes a clear distinction between patient education and discharge instructions, Birmingham points out. “The staff can do a great job on educating the patient about his disease, but they need to provide detailed, written discharge instructions,” she says. For instance, tell a patient with diabetes, “‘Call your doctor if your glucose level is above 100 or below 60,’ and include the physician’s contact information,” she says.