CMS updates discharge planning guidelines

Document emphasizes importance of a plan

Continuing to stress the importance of discharge planning and preventing unnecessary readmissions, the Centers for Medicare & Medicaid Services (CMS) has issued a revised set of Discharge Planning Interpretive Guidelines that surveyors will use to assess a hospital's compliance with Medicare's Conditions of Participation. The guidelines do not apply to critical access hospitals, which must follow a different set of Conditions of Participation.

"There is increased emphasis on discharge planning by CMS, and these revised guidelines attest to the importance of a good discharge plan and a smooth transition, which can help to prevent unnecessary readmissions. CMS is encouraging hospitals to develop a discharge plan for all inpatients, whether they are Medicare recipients or not," says Sue Dill Calloway, RN, MSN, JD, CPHRM, CCM, CCP, president of Patient Safety Education and Consulting in Dublin, OH.

CMS cites statistics that say one in five patients is readmitted within 30 days after discharge and a third of patients (34%) are readmitted in 60 days. Poor discharge planning and failure to do a plan of care can lead to readmissions, Dill Calloway says.

The 39-page document outlines what CMS expects hospitals to do in order to comply with the Conditions of Participation regulations and interpretive guidelines and includes instructions on what the surveyors should assess when they review hospital records. They include specific criteria for evaluating patients, creating a discharge plan, and improving transitions from the hospital to home or another level of care.

"Surveyors will be looking for documentation that hospitals are complying with the Conditions of Participation and initially will select a group of charts to review for evidence of discharge planning evaluation activities. If they see a pattern of non-compliance, they may review more charts, order the hospital to create an action plan for improvement, then come back for another review," says Jackie Birmingham, RN, MS, vice president emerita, clinical leadership for Curaspan Health Group. Ultimately, not being in compliance could lead to a loss of Medicare funding, she adds.

Birmingham suggests that case managers familiarize themselves with the guidelines and what the surveyors will be checking and use them as a guide for developing best practices for patient care and transitions.

New in this version of the Interpretive Guidelines are what CMS call "blue boxes," a tool that hospitals can use to promote better outcomes. The "blue boxes" make suggestions that hospitals can use in improving discharge planning and care transitions but are not required for compliance.

The Interpretive Guidelines describe the four-stage discharge planning process required by the Conditions of Participation, including screening all patients as part of the admission assessment to determine their risk for readmission; evaluating the post-discharge needs of all patients identified by the assessment or when the physician requests an evaluation; developing a discharge plan; and implementing the discharge plan.

For the first time, CMS asks surveyors to employ the tracer methodology on several closed and open inpatient records to determine if hospitals comply with the Conditions of Participation. The guidelines specify that surveyors determine that there was a screening done to identify patients who need a discharge evaluation, if the hospital staff can demonstrate that the hospital's criteria and screening process for a discharge evaluation is correctly applied, and if there is a process to update the conditions or circumstances of patients if they were not initially identified as needing a discharge plan.

The revised interpretive guidelines provide more details about the hospital's role in ensuring a smooth transition as patients move from one setting to another and emphasize the importance of thorough evaluation of patients' post-discharge needs and timely discharge planning. They have a new emphasis on hospitals' relationships with post-acute providers and making sure that care can be provided in the setting to which the patients transition. Here are some of the highlights:

The guidelines specify that a discharge plan must be created by an RN, a social worker, or another qualified person and discuss what discharge planners should consider in developing a discharge plan. Factors that should be taken into account when the discharge plan is created include functional status and cognitive ability, living situation, support at home, and the type of services the patient will need after discharge, Dill Calloway says.

"CMS wants discharge planners to assess that the patient's discharge needs can be met in their previous living environment and that patients and/or family members have the ability to take care of the patient's needs after discharge. If not, the discharge planners should make sure that there are community-based services that can provide the care and that needed services are in place when the patient is discharged," she adds. In addition, CMS discusses that the staff should evaluate the patient and family's ability to pay for post-acute services.

Make sure patients and caregivers fully understand what the patient will need after discharge and can demonstrate the tasks they will need to perform, such as dressing changes or injections, she adds.

Discharge planners should engage patients and family members in developing the plan of care and assist them in making informed decisions about post-discharge options, Dill Calloway says. "CMS emphasizes involving patients and families in the plan of care and points out that they will be more likely to follow the plan if they are involved in creating it. Discharge planners need to ask about what a patient can do or what the family is willing to do before creating a discharge plan," she says. For instance, family members may resist discharging a patient to a skilled nursing facility for a short time if they are willing to provide the care the patient will need at home.

The document calls for the identification of patients who need discharge planning early in the hospital stay. CMS recommends that the discharge planning process be performed at least 48 hours before discharge and requires surveyors to make sure the discharge wasn't delayed because the discharge planner didn't do a timely discharge evaluation.

If hospitals don't evaluate all patients for post-discharge needs, they should have a system to ensure that there is a way for the discharge planning staff to learn if a patient's condition changes to the point that he or she will need post-discharge services.

"The message is that hospitals should develop a system where discharge planners see every patient every day or review the record daily, or that there is a system where the staff makes discharge planners aware of if a patient's condition changes," Dill Calloway says. For instance, a patient who is expected to go home with no services may develop a deep venous thrombosis and may need home health. If the discharge planner isn't looking at the chart every day and the nurse doesn't notify the discharge planner, the patient could develop problems at home and have to be readmitted.

To read the guidelines, see


Sue Dill Calloway, RN, MSN, JD, CPHRM, CCM, CCP, President Patient Safety Education and Consulting, Dublin, OH. e-mail: