How is your discharge planning process?

Following discharge surveys come new CoPs

It always comes down to communication, right? In an effort to further emphasize improved communications along the healthcare continuum, the Centers for Medicare & Medicaid Services (CMS) has revised its Conditions of Participation (CoPs) for discharge planning. This comes just as the organization will begin doing surveys related to discharge planning procedures.

The revised CoPs include rules for patients being discharged home, as well as to skilled nursing facilities, rehabilitation centers, home health agencies and other post-acute service centers.

Hospitals have to have a four-stage process in place that includes requirements on screening, evaluation, and implementation. Hospitals are encouraged to get input from throughout the healthcare continuum, including nursing homes, home health agencies, primary care physicians, and clinics.

The new CoPs also include policies related to documenting patients who do not want to participate in the discharge planning process.

Hospitals should begin reviewing the new CoPs, which were released in mid-May, immediately, says Abby Pendleton, a founder of The Health Law Partners in Detroit. While some of the changes are merely recommendations that are not mandatory and for which you cannot be cited, Pendleton says you should consider including them in your discharge planning processes anyway. “At minimum, hospitals should ensure that the detailed requirements set forth in the document are incorporated into the discharge planning policies.”

The biggest changes in the CoPs relate to the adoption and implementation of a four-stage protocol for creating discharge plans for patients. The policies hospitals create have to address each requirement of the regulation and be in writing. While it’s not required, the revised CoPs recommend adopting a policy of creating a discharge plan for every single inpatient, rather than just those who risk assessment or physician and patient request bring to your attention. If that isn’t feasible, says Jessica Gustafson, another founding partner at The Health Law Partners, document the criteria and screening process used to identify patients likely to need discharge planning, including the evidence or basis for the criteria you choose and process used. You must also document which staff members have responsibility to carry out the screening and evaluation.

No time definitions

“This screen must take place ‘at an early stage’ of a patients hospitalization,” Pendleton says. That “early stage” isn’t defined, but she says that surveyors won’t issue a citation if the screening is done at least 48 hours before the patient is discharged.

The new requirements also demand that hospitals have a way of making patients or their representatives aware that they can request a discharge planning evaluation even if an initial screen shows they aren’t at risk for a post-hospitalization adverse event.

Whatever tool you use for evaluation, it has to have been developed by a nurse, social worker or “other qualified personnel or by a person who is supervised by such personnel.” The hospitals ideally should use a multidisciplinary team to create the evaluation, says Gustafson.

That evaluation needs to be a detailed review of a patient’s expected post-discharge needs, Gustafson continues. Specific areas that have to be addressed in the discharge plan should be noted — medication reminders, special dietary needs, or daily weighing, for example. It should include an assessment of the patient’s ability or lack of ability to take care of him- or herself, with the goal being to get the patient back to the same setting from which he or she came to the hospital.

There is no specific time guideline for doing the evaluation — Pendleton notes the CoPs just say it should be done in a timely manner. But there is a suggestion that 24 hours is a good benchmark to determine if an evaluation was initiated within good time. If it was not done within 24 hours, the reason why not should be indicated.

The results of the discharge planning evaluation should be documented in the patient’s medical record and must be discussed with the patient or his or her representative.

While a patient’s wishes are important, the CoPs note that hospitals do not have to develop a discharge plan that cannot or should not be implemented because the patient’s wishes are unrealistic, Gustafson says. But if the patient’s physicians request a plan be developed, you have to complete it.

The hospital has to get the ball rolling on the discharge plan. That means providing any required in-hospital education or training to the patient or the patient’s family, making any referrals for outpatient or skilled nursing care placement if appropriate, and ensuring patients that need skilled nursing or home health services get a list of providers who can give them the care they need.

The plan needs to be updated if the patient’s condition alters, and that leads to a change in what would the patient requires after discharge, Gustafson notes.

Outpatients do not need a discharge plan, and hospitals aren’t required to create them. But in some cases, it is suggested. For example, Pendleton says, patients using outpatient observation services might benefit from an abbreviated discharge plan.

So far, Pendleton and Gustafson haven’t had a lot of calls from clients concerned about the new CoPs. But both note that the detail in the requirements is substantial, and some organizations will have to think carefully about how to implement them. “There may also be challenges with the implementation of the patient wish component,” says Pendleton.

There’s good reason to move forward, though: Recent research has shown that assessing the risk of patients as part of discharge planning can help reduce unplanned 30-day readmissions1. Given CMS’ focus on that metric, it seems worth it to give your discharge planning the once over, too.

For more information on this story, contact Jessica Gustafson or Abby Pendleton, The Health Law Partners, Detroit, MI. Telephone: (248) 996-8510.


1. Donze J, Aujesky D, Williams D, Schnipper JL. Potentially Avoidable 30-Day Hospital Readmissions in Medical PatientsDerivation and Validation of a Prediction Model JAMA Intern Med. 2013;173(8):632-638. doi:10.1001/jamainternmed.2013.3023.