In the proposed changes of the discharge planning portion of the Medicare Conditions of Participation (CoPs), CMS reaffirms the goal of preventing hospital readmissions by ensuring safe transitions.

Among the requirements of the proposal are post-discharge follow-up by the hospital, ensuring that patients see a primary care provider after discharge and that the provider has detailed information on the hospital stay within 48 hours of discharge, assisting patients in choosing a post-acute provider that can meet their individual needs, and making sure that the receiving provider has all the information needed to help the patient recover and stay out of the hospital.

All hospitals — including critical access hospitals — must establish a process for post-discharge follow-up, points out Jackie Birmingham, RN, BSN, MS, CMAC, vice president emerita of clinical leadership for Curaspan, a Newton, MA-based consulting firm. This requirement will be a cost burden for many hospitals, she adds.

“When case managers call patients after discharge, they will have to ask standard questions and if something is wrong, they have to take some kind of action. For case managers with a caseload of 30 patients, the phone calls may take longer than the discharge plan,” she adds.

Case management directors and hospital leaders should think carefully about the best way to meet the criteria, Birmingham says. “There’s not a perfect solution. It will be impossible for hospitals to call everybody without some technology unless they add significant staff,” she adds.

Follow-up may be an extension or enhancement of what is currently in place at many hospitals, says Donna Turtle, FACHE, MPH, RN, director at Huron Consulting, a Chicago-based healthcare consulting firm. Many hospitals are already calling at least some of their patients within 48 hours after discharge to ascertain if they are having problems, if they understand their discharge instructions, or are having difficulty getting any of the post-discharge services they need, she adds.

One challenge for case managers is going to be arranging a post-discharge follow-up appointment for patients who are admitted through the emergency department and have no primary care physician, says Larry Magras, MD, MBA, FACPE, senior director at Huron Consulting. “When patients are not connected to a primary care physician, follow-up becomes more labor intensive,” he says.

“The biggest challenge for case managers will probably be the requirement to have the discharge summary and discharge instructions in the hands of the primary care provider within 48 hours,” says Sue Dill Calloway, RN, MSN, JD, CPHRM, CCM, CCP, president of Patient Safety Education and Consulting in Dublin, OH. When patients are ready to be discharged, case managers need to make sure the attending physician dictates the discharge summary into the medical records, Dill Calloway says. “Getting this done may be challenging for case managers,” she says.

About a third of patients go home with test results pending and many times the primary care physicians don’t even know about the tests, Dill Calloway points out. The proposed rules require hospitals to make sure that pending test results are sent to the primary care provider within 24 hours after they are available, she adds.

The discharge instructions form should have a box that indicates pending tests, Dill Calloway says. When additional tests are ordered by the treating physician, she recommends that the tests be scheduled before the patient is discharged.

“If you just write in the discharge instructions that the physician wants another test and don’t schedule it and nobody makes sure the test is performed, it may get lost in the system,” she says.

When patients are referred for post-acute services, the proposed rule mandates that hospitals assist the patients and their families in choosing a provider, Birmingham says. Patients will still have the freedom to choose their facility, but it should be from among a list of providers that can meet their needs, she adds.

“Instead of asking a patient to choose and finding out that the facility may not have a bed or can’t provide the needed care, search for available and appropriate facilities and give the patient a list of those,” she says. Document in the patient’s record that you presented the list, she adds.

The rule also requires the hospital to verify that post-acute providers are in the managed care network if patients are enrolled in a managed care organization, Birmingham adds.

The hospital also must inform the patient or family member of their freedom to choose and identify any skilled nursing home or home health agency in which the hospital has a disclosable financial interest.

The IMPACT Act requirements for post-acute providers to track the same data will enable patients to make a well-informed decision about post-acute care, Magras says. “CMS is proposing that the patient and family must be involved not only in the plan of care in the hospital, but the discharge plan. The new regulations call for helping patients and their families select a post-acute provider by sharing data on quality measures and other information on post-acute providers. It put the power of information in the hands of the patient,” Magras says.

The proposed rule outlines specific information hospitals must provide to receiving providers. (For details, see box in this issue.)

Hospitals should consider rewriting their transfer forms to make sure they contain all the information necessary to meet the requirement, Dill Calloway says.

If your hospital uses an electronic health record, Birmingham recommends reviewing the Continuity of Care Document in the electronic health record software. “The Continuity of Care Document lists basic clinical information that must be communicated from one provider to another. It is intended to include only the information critical to effectively continue care,” Birmingham says.

Birmingham suggests that the case manager review the information contained in the CMS rule to determine whether it will be important to the next provider of care. She cautions case managers to check with their hospital policy and state regulations before sending any information to the next provider.

A webinar, “The IMPACT Act and Its Effect on Discharge Planning Standards,” by Sue Dill Calloway will be presented by AHC Media on Feb. 8, 2016, from 3 p.m. to 4:30 p.m. EST. For more information, visit