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Continuity of care

October 14th, 2016

Hospitals may also want to consider redrafting their continuity of care or transfer form. Now the proposed regulations list a number of things that need to be included in the transfer form. This includes demographic information including name, sex, date of birth, race, ethnicity, and preferred language. The transfer form must include advance directives, course of illness and treatment, procedures performed, diagnosis, lab tests, results of diagnostic testing, consult results, functional status assessment, psychosocial assessment, including cognitive status, social support, behavioral health issues, medication reconciliation, allergies, immunizations, smoking status, vital signs, implantable device identifier, and patient goals and preferences.

Generally, in the past if a patient needed long term care or home health, the patient was informed about their freedom of choice. They were given a list of ones that served the geographical area to pick from. This continues but also applies to inpatient rehab facilities and long term care hospitals. If the patient is in a managed care organization, it must disclose which ones are accepted and must verify them. The hospital must document that the list was given. The patient is not required to have the patient sign this but some hospital do have the patient sign an attestation to this effect. The hospital must continue to disclose any financial interest in any of the skilled nursing facilities or home health agencies.

There is also required discharge planning regulations for home health agencies. Home health agencies should review these carefully. There are similar discharge planning requirements for critical access hospitals.