The trusted source for
healthcare information and
The hospital may want to consider redrafting the discharge planning evaluation form to include the CMS requirements. This includes, but is not limited to, admitting diagnosis, relevant co-morbidities, past medical history, past surgical history, anticipated needs, readmission risk, and relevant psychosocial history. Communication needs must be assessed, including language barriers, diminished eyesight, diminished hearing, and self-reported literacy of either the patient or caregiver. The assessment must include the patient’s goals and treatment preferences and access to non-health care services. This might include someone to transport the patient to their first appointment, preparation of meals when needed, shopping, or housekeeping services.
The hospital must assist patients or their families select a post-acute provider. This includes home health services, a skilled nursing facility, an inpatient rehab facility, or long-term care acute hospitals. The hospital must share data on the five quality measures and on resource use measures. Hospitals must take into account quality, resource use, and other measures in discharge planning.
Often an RN will do an admission assessment. The results may prompt notification of the discharge planner or social workers. The patient’s discharge needs and discharge plan must be documented in the medical record.
The hospital must assess its discharge planning process regularly. It must review a sample of discharge plans and include reviews of patients readmitted within 30 days.
If a patient is discharged home, CMS has mandates for the discharge instructions. These must be provided to the patient and/or their support person. If the patient is going to be seen by a post-acute care provider, such as a home health nurse, then these must be provided to them as well. The discharge instructions must include written information on warning signs and symptoms that would indicate the patient needs to call their doctor or return to the hospital.