Final Rule Revises Discharge Planning Requirements
CMS moves to empower patients to be more active participants in the discharge planning process.
A final rule revises and implements discharge planning requirements that hospitals, critical access hospitals (CAHs), and home health agencies (HHAs) must meet as a condition of participation (CoP) in the Medicare and Medicaid programs. These facilities have until Nov. 29, 2019, to institute the provisions in the Revisions to Discharge Planning Requirements Final Rule [CMS-3317-F].
The final rule, published in the Sept. 30 Federal Register, gives hospitals, HHAs, and CAHs 60 days to comply. That doesn’t sound like nearly enough time to put in place revised discharge planning requirements, but hospitals have had years to prepare — the proposed rule was first published in 2015.
With the exception of the discharge planning requirements of the IMPACT Act (see 482.43(a)(8)), the Centers for Medicare & Medicaid Services (CMS) says hospitals and CAHs are already conducting most of the revised discharge planning requirements.
CMS states in the final rule,
The current hospital CoPs already require hospitals to send along with any patient that is transferred or referred to another facility the necessary medical information for the patient’s follow-up or ancillary care to the appropriate facility (at § 482.43(d) prior to finalization of this rule). Overall, we believe that almost all of the changes for hospitals constitute a clarification and restatement of the current requirements along with their interpretive guidelines, or simply state as requirements practices that most hospitals already follow for most patients.
The affected hospitals, which include short-term acute-care hospitals, long-term care hospitals (LTCHs), rehabilitation hospitals, psychiatric hospitals, children’s hospitals, and cancer hospitals, are now tasked with learning what the requirements are for “discharge planning,” which is the process of preparing to move patients from acute care into post-acute care (PAC), and implementing those changes.
Provisions in Brief
- Hospitals/CAHS must supply patients with their medical records within a reasonable time frame.
- Hospitals/CAHS must actively use a discharge planning process that involves patients and/or patients’ representatives and takes into account data on quality measures and resource use measures.
- Hospitals/CAHs must discharge, transfer, or refer patients with their applicable medical information at the time of discharge, transfer, or referral.
Part 482 CoP for Hospitals
Section 482.43 is revised to read:
The hospital must have an effective discharge planning process that focuses on the patient’s goals and treatment preferences and includes the patient and his or her caregivers/support person(s) as active partners in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to preventable hospital readmissions.
(a) Standard: Discharge planning process. The hospital’s discharge planning process must identify, at an early stage of hospitalization, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. [CMS did not finalize the proposed design requirements.]
(1) Any discharge planning evaluation must be made on a timely basis to ensure that appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge.
(2) A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to, hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services.
(3) The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative).
(4) Upon the request of a patient’s physician, the hospital must arrange for the development and initial implementation of a discharge plan for the patient.
(5) Any discharge planning evaluation or discharge plan required under this paragraph must be developed by, or under the supervision of a registered nurse, social worker, or other appropriately qualified personnel.
(6) The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(7) The hospital must assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were readmitted within 30 days of a previous admission, to ensure that the plans are responsive to patient post-discharge needs.
(8) The hospital must assist patients, their families, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The hospital must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences.
(b) Standard: Discharge of the patient and provision and transmission of the patient’s necessary medical information. The hospital must discharge the patient, and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care.
(c) Standard: Requirements related to post-acute care services. For those patients discharged home and referred for HHA services, or for those patients transferred to a SNF for post-hospital extended care services, or transferred to an IRF or LTCH for specialized hospital services, the following requirements apply, in addition to those set out at paragraphs (a) and (b) of this section:
(1) The hospital must include in the discharge plan a list of HHAs, SNFs, IRFs, or LTCHs that are available to the patient, that are participating in the Medicare program, and that serve the geographic area (as defined by the HHA) in which the patient resides, or in the case of a SNF, IRF, or LTCH, in the geographic area requested by the patient. HHAs must request to be listed by the hospital as available.
(i) This list must only be presented to patients for whom home health care post-hospital extended care services, SNF, IRF, or LTCH services are indicated and appropriate as determined by the discharge planning evaluation.
(ii) For patients enrolled in managed care organizations, the hospital must make the patient aware of the need to verify with their managed care organization which practitioners, providers or certified suppliers are in the managed care organization’s network. If the hospital has information on which practitioners, providers or certified supplies are in the network of the patient’s managed care organization, it must share this with the patient or the patient’s representative.
(iii) The hospital must document in the patient’s medical record that the list was presented to the patient or to the patient’s representative.
(2) The hospital, as part of the discharge planning process, must inform the patient or the patient’s representative of their freedom to choose among participating Medicare providers and suppliers of post-discharge services and must, when possible, respect the patient’s or the patient’s representative’s goals of care and treatment preferences, as well as other preferences they express. The hospital must not specify or otherwise limit the qualified providers or suppliers that are available to the patient.
(3) The discharge plan must identify any HHA or SNF to which the patient is referred in which the hospital has a disclosable financial interest, as specified by the Secretary, and any HHA or SNF that has a disclosable financial interest in a hospital under Medicare.
CMS did not finalize its proposal to require hospitals to send a copy of the discharge instructions and the discharge summary within 48 hours of the patient’s discharge; pending test results within 24 hours of their availability, and all other necessary info, as specified in proposed Section 482.43(e)(2).
Newly add Part 485 – CoP Specialized Providers, Section 485.642 reads the same as Section 482.43, but insert “CAH” in place of “hospital.”
Part 484 HHA
Section 484.58 is added to read:
(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences.
(b) Standard: Discharge or transfer summary content.
(1) The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post- discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care.
(2) The HHA must comply with requests for additional clinical information as may be necessary for treatment of the patient made by the receiving facility or health care practitioner.
CMS is not requiring hospitals to consult with their state’s Prescription Drug Monitoring Program (PDMP) and review a patient’s risk of non-medical use of controlled substances and substance use disorders as indicated by the PDMP report, nor are they requiring providers to use or access PDMPs during the medication reconciliation process.
“However,” CMS says in the final rule, “as discussed in the proposed rule, we strongly encourage practitioners to utilize strategies and tools, such as PDMPs, to the extent permissible under the HIPAA Privacy Rule and state law, to help to reduce prescription drug misuse.”