CMS gives tips on discharge planning

Suggestions not mandatory

In the newly revised Discharge Planning Interpretive Guidelines, the Centers for Medicare & Medicaid Services (CMS) includes what it calls "blue boxes" that advise hospitals on best practices in discharge planning and care transitions.

CMS suggests that hospitals voluntarily adopt these practices to promote better outcomes but states that they are not mandatory and surveyors will not assess the hospital's compliance during the survey process.

Here are some of the practices CMS advises hospitals to adopt:

• Consider providing an abbreviated post-hospital planning process for some outpatients, such as those receiving observation services or being discharged from same-day surgery and some patients being discharged from the emergency department. "Given the increasing complexity of services offered in the outpatient setting, many of the same concerns for effective post-hospital care coordination arise as for inpatients," the guidelines state.

• When you develop discharge processes, include input from post-acute facilities and professionals, such as home health agencies and primary care physicians, who provide care to discharged patients, as well as patients and patient advocacy groups.

• Provide a discharge plan for every inpatient to reduce the risk of problems after the patient leaves the hospital if the screening process doesn't adequately identify patients who need post-discharge planning.

• Take a multidisciplinary approach to discharge planning and include representatives from nursing, case management, social work, medical staff, pharmacy, and other healthcare professionals involved with the patient's care.

• Document it in the medical record if patients exercise their right to refuse to participate in discharge planning or to implement a discharge plan.

• To improve care transitions, schedule follow-up appointments with the patient's primary care physician, fill prescriptions before discharge, if appropriate, arrange remote monitoring technology, and follow up with phone calls within 24 to 72 hours after discharge.

• Refer patients and their families to Nursing Home Compare and Home Health Compare websites to help them in choosing post-acute providers.