Having a robust, detailed discharge planning process is more important now than ever before. Our patients are older, with more co-morbidities, lengths of stay are shorter, coverage for outpatient supportive services is limited and the family unit available to provide support is often no longer intact. We are not the only ones worried about the discharge planning process. The Centers for Medicare and Medicaid Services ( CMS) in June 2023, issued a QSO memo, reiterating the requirements for hospital discharges focusing on those who will need ongoing care from post-acute care providers. While CMS’s role is to be our advocate for high quality, safe care they also are the shepherd or financial manager for our Medicare and in many ways Medicaid Insurance plans. CMS reports that the hospital readmission rate in 2023 was approximately 14.5%. This means on average 14.5% of patients discharged from the hospital were readmitted within 30 days. Having a highly functional discharge planning process is essential for both health care providers and patients, but what are the required elements and processes that make a process highly functional, and is your organization ready for the latest changes to the CMS discharge planning requirements?
The purpose of discharge planning.
An effective discharge planning process focuses on the patient’s goals and treatment preferences. It includes both the patient and their caregiver or support person(s) as active participants in the planning process. The patient’s goals and treatment preferences along with creating a smooth transition process from inpatient care providers to outpatient care providers while focusing on reducing factors that lead to avoidable hospital readmissions is the recipe for a robust, successful discharge planning process.
Key Components of Discharge Planning
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Discharge planning begins upon admission.
Perhaps a better statement would be discharge planning begins upon arrival. Assessing the patients’ needs for post-acute care creates the foundation for the plan. This assessment is commonly known as the discharge planning evaluation. The evaluation should address key factors such as the perceived need for post-acute care services, the patient’s degree of independence, availability of their caregiver/support team to assist them and their ability to provide self-care. Additional factors that should influence our discharge plan are those factors identified from our social determinants of health patient assessment. For instance, factors that affect a person’s ability to access medications, access post-acute care service locations , food and housing insecurities should weigh heavily on the discharge plan.
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Medication Reconciliation is an essential component of the discharge planning process.
Ensuring that the patient is provided clear instructions on which medications they should be taking after discharge is essential to the health of the patient. This should include comparing the patient’s pre-admission medications to those being prescribed upon discharge. Considerations should include any identified social determinants that need to be accommodated. For instance, many health care organizations utilize a formulary management system for the medications they make available within their hospitals. Automatic medication substitutions occur routinely as a means to control hospital costs without compromising patient care. But upon discharge, the patients ability to afford what seems to be simple changes in medication therapy can make continuation of the therapy unaffordable for the patient.
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Continuous reassessment of the discharge plan.
Things move quickly within the hospital environment. Patient conditions can improve or deteriorate right in front of our eyes. Continuous review and discussion of the discharge plan with the patient and caregiver/support team is essential. Ensuring that each external agency that will be engaged in the ongoing delivery of care outside the four walls of the hospital needs to be coordinated to avoid any gaps in the care process. Modifications to the discharge plan are perfectly acceptable provided the patient and/or caregiver/support team are in agreement.
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Patient Choice
In alignment with the CMS Hospital Conditions of Participation Patient’s Rights and Responsibilities, the patient has the right to choose their next level of care provider. Federal law requires acute care providers to supply each patient with a list of providers that offer the services the patient requires. This list must also include data on quality measures and data on resource use measures for each listed entity. This supports the patients right to make informed decisions about their care.
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Communication of essential medical information
In order to execute a smooth transition, essential medical information must be shared with the next care provider. Core information that must be shared include:
- Patient’s current course of illness and treatment
- Post-discharge goals of care and treatment preferences
Transfer Protocols
A new requirement that takes effect July 1, 2025, is that the hospital must have written policies and procedures for transferring patients under their care (inclusive of inpatient services) to the appropriate level of care as needed to meet the needs of the patient. The new requirements include the mandate for the provision of annual training to relevant staff regarding the hospital policies and procedures for transferring patients under its care.
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Discharge planning process evaluation
Regular evaluation of the hospital’s discharge planning process is both essential and required by CMS. The evaluation must include a review of a sampling of executed discharge plans, inclusive of a sub-sample of patients who were readmitted within 30 days of discharge to determine if the plans were responsive to the patient’s post-discharge needs.
Highly functional, robust discharge planning processes are essential to hospital operations. Surveyors will look at both closed records and open medical records to assess the discharge planning and execution process. Open medical record reviews may include interviewing of the patient and/or caregiver/support team members to assess their level of engagement in the process, understanding of the options available, selection process and their role in executing the discharge plan.
Please contact us for questions or more information at 704-573-4535 or info@courtemanche-assocs.com.
Courtemanche & Associates specializes in Healthcare Accreditation and Regulatory Compliance Consulting Services. With over 30 years of being in business and 100+ years of healthcare experience amongst our consulting team, we are ready to assist with your accreditation and regulatory compliance needs.
