By Toni Cesta, PhD, RN, FAAN


In 2015, the Centers for Medicare & Medicaid Services (CMS) introduced proposed rules for discharge planning. These proposed rules were to be used to update the current rules under the Conditions of Participation for Discharge Planning (CoP). In 2019, CMS provided the elements of the proposed rules that would be adopted in November 2019. While the selected rules may not be as dramatic as the entire set of proposed rules, some of the new rules will require changes in how case management departments perform some components of discharge planning. This month, we will discuss the current rules, the proposed rules, and the final rules published in 2019.

Federal Guidelines for Discharge Planning

CMS describes discharge planning as a process, not an outcome.1 Because it is a process, case management professionals should always follow the CoP for discharge planning, as well as their department’s policies and procedures. In this way, one can ensure one’s practice and department are compliant.

The process begins at the point of admission, and continues until the patient is safely in the community. It should be noted that discharge planning also occurs in skilled nursing facilities, acute care, and home care. In other words, discharge planning allows for a smooth move for the patient across the continuum, and at all transition points. As discharge planners, case management professionals are responsible for ensuring that the patient’s discharge is timely, safe, and appropriate.

Current Rules and Regulations for Discharge Planning

CMS requires the Health and Human Services Secretary to develop discharge planning guidelines to ensure a timely and smooth transition to the most appropriate post-hospital care. It is important to understand these federal regulations only apply to the following entities. Please note these entities are all acute care:

• Medicare and Medicaid participating hospitals;

• Short-term psychiatric;

• Rehabilitation;

• Long-term, children’s, and alcohol/drug facilities.

The process standards go on to say that hospitals must:

• Identify patients in need of discharge planning early in their hospitalization. While CMS does not specify when to perform the initial discharge planning evaluation, best practice calls for it to be completed on the day of admission whenever possible.

• Provide a discharge planning evaluation for those identified patients, or at the request of the patient, representative, or physician. CMS only requires evaluation of patients who are identified for a discharge plan, or when someone requests one. Best practice tells us that all patients should receive a discharge planning evaluation.

• Complete the evaluation early to ensure appropriate arrangements are in place before discharge to avoid unnecessary delays. This reinforces the best practice of assessing the patient on the day of admission.

• Include in the evaluation the patient’s need for appropriate post-hospital services, and the availability of such services. This is the foundation of the case management admission assessment.

• Include the evaluation in the patient’s medical record. The results must be discussed with the patient or representative.

• Arrange for the development and initial implementation of a discharge plan.

• Develop the plan under the supervision of a registered nurse, social worker, or other qualified personnel. Typically, registered nurse or social work case managers complete the discharge planning assessment. CMS says other personnel can complete the assessment under the supervision of the nurse or social worker. It is critical to educate these other professionals in the discharge assessment and planning process.

• Be consistent with Section 1802 (Freedom of Choice) by not specifying or limiting qualified providers. Identify any provider in which the hospital has a financial interest. This can be achieved by placing an asterisk in front of any of these providers with a footnote explaining their financial interest.

Exceptions for Medicare Advantage Plans

Understand these two elements of Medicare Advantage plans:

• The discharge planning evaluation is not required to include information on the availability of home health services through individuals and entities that do not have a contract with the organization.

• The plan may specify or limit the provider (or providers) of post-hospital home health services or other post-hospital services under the plan. This means that a Medicare Advantage patient’s choice list should be limited to those providers that are contracted with the patient’s managed care plan.

The Conditions of Participation

The current federal standards for hospitals participating in the Medicare and Medicaid programs are presented in the Code of Federal Regulations (CFR) as 13 Conditions of Participation (CoPs). The original CoPs were written in 1983, and were developed to ensure quality standards in hospitals and other provider settings. They became the foundation for improving quality and protecting the health and safety of Medicare and Medicaid beneficiaries. Today, the CoPs are managed under the Department of Health and Human Services. While all the CoPs are important, the two that apply most closely to case management include Section 482.30 (Utilization Review) and 482.43 (Discharge Planning). Each of these represents core roles that case management professionals perform, and will be our focus this month. To find information on the entire Conditions of Participation, visit:

The 13 Conditions of Participation include these categories:

• Quality assessment and performance improvement program;

• Medical staff;

• Nursing services;

• Medical record services;

• Pharmaceutical services;

• Radiologic services;

• Laboratory services;

• Food and dietetic services;

• Utilization review;

• Physical environment;

• Infection control;

• Discharge planning;

• Organ, tissue, and eye procurement.

CMS CoP for Discharge Planning

The following requirements outline the rules as they relate to discharge planning:

• The hospital must establish a discharge planning process for all patients. The hospital’s policies and procedures must be specified in writing.

• Patients who require discharge planning evaluation must be identified early in the hospital stay. Evaluations also should be provided to other patients at the request of the patient, the person acting on the patient’s behalf, or the physician.

• The evaluation should determine the likelihood of the patient needing post-hospital services, and availability of the services.

• Case managers must determine the patient’s capacity for self-care, or the likelihood of needing home care services.

• Include evaluation in the medical record, and discuss the results with the patient or his or her representative.

The Discharge Plan

• A patient’s physician can request a discharge plan. The hospital must develop discharge plan for patient.

• The discharge planner must arrange for plan implementation.

• Reassess discharge plan if care needs change.

• The patient and family members or interested persons must be counseled to prepare them for post-hospital care.

• The hospital must transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care.

• The hospital must continually reassess its discharge planning process. This should include a review of discharge plans to ensure they are appropriate for patient needs.

Conditions of Participation for Patient Choice

• In the discharge plan, include a list of HHAs or SNFs available to the patient that participate in Medicare, and serve the geographic area in which patient resides. SNFs must serve the geographic area requested by patient; HHAs must request to be listed by the hospital.

• The list should only be present to patients for whom home healthcare or post-hospital extended care services are indicated and appropriate.

• For patients enrolled in managed care organizations, the hospital must indicate availability of home health and post-hospital extended care services through individuals and entities that have contracted with the managed care organizations.

• Document that the list was given to the patient and/or the patient’s representative.

At this time, choice lists need only be given for patients transferring to home health or to a SNF. While you can provide choices for other discharge destinations, you have no regulatory requirement to do so.

CMS Conditions of Participation Final Discharge Planning Rules: 2020

The new rules for discharge planning went into effect on Nov. 29, 2019, which represents federal fiscal year 2020. New CoP rules apply to hospitals and home health agencies. Facilities that must adhere to the new rules include:

• Acute care hospitals;

• Long-term care hospitals;

• Inpatient rehab facilities;

• Inpatient psychiatric facilities;

• Children’s hospitals;

• Cancer hospitals;

• Critical access hospitals.

CMS estimates that hospitals and home health agencies will spend $215 million per year to comply with the discharge planning changes, and will incur an additional $46.5 million in one-time costs. CMS is hoping the new rules will allow patients to make healthcare decisions that are right for them, and gives them transparency into what can be a confusing process.

The New Rules for Discharge Planning

• Focus on patients’ goals of care and treatment preferences. Providers are required to consider the patient’s health objectives and care preferences during the discharge planning process to ensure that patients receive the desired care.

• Assist patients, families, or representatives in selecting post-acute care service providers or suppliers by sharing data on quality and resource use measures that are relevant to patients’ goals of care and treatment preferences.

• Hospitals and home health agencies are required to transfer and refer patients along with necessary medical information — including course of illness and treatment — to post-acute services, providers, facilities, agencies, and other patient service providers and practitioners responsible for patient’s follow-up care to ensure a safe transition.

• Provide additional clinical information for patients if requested by receiving facilities.

• Ensure patients can access their medical records when requested.

• Use quality and resource measures relevant to patients’ goals of care and treatment preferences in the discharge planning process. This is aimed to increase the use of quality data as a decision-maker in selecting post-acute providers.

Implementing the New Rules

The first thing to consider is focusing on including the patient’s goals and preferences in the planning process. This means a case manager must consider alternatives when the patient’s goals diverge from the initial discharge plan. This can be difficult as issues such as availability and insurance coverage will have to be considered.

Next, discharge planners must share data from post-acute care providers with patients. These include quality data such as star ratings and outcomes data, where appropriate.

The third issue is the need to include the caregiver or support person along with the patient to develop the discharge plan. This means the case manager must discuss the plan and preferences with the patient’s family or other supports along with the patient, when appropriate, and ensure they agree with the plan. This applies to anyone who will be caring for the patient after discharge.

Finally, CMS requires sending a standard data set of the patient’s medical information to the post-acute provider at the time of transfer. The change here is that it must be in either electronic or written format.


As case managers implement new rules, be sure to include parameters for correct documentation. This should include the original and the new rules. Without documentation of these tasks in the medical record, case managers will not receive will not get credit for completing them. This can result in a negative audit outcome, so be diligent in understanding as well as implementing the rules.


  1. Centers for Medicare & Medicaid Services. Glossary: Discharge Planning. Available at: