This document provides an overview of the current rules and regulations for discharge planning according to the Centers for Medicare and Medicaid Services (CMS). It discusses key aspects of discharge planning including definitions, foundations of effective discharge planning, consequences of ineffective discharge planning, and current rules and regulations. The rules are aimed at improving quality of care and patient safety during transitions from one level of care to another.
Discharge planning rules and conditions of participations
1. AN UPDATE ON THE CMS
DISCHARGE PLANNING
RULES AND REGULATIONS
FOR 2019
Toni G. Cesta, Ph.D., RN, FAAN
Partner and Consultant
Case Management Concepts, LLC
East Coast Office
North Bellmore, New York
2. DEFINITION OF DISCHARGE
PLANNING
“A process used to decide what a patient needs for a smooth
move from one level of care to another. This is done by a
social worker or other health care professional. It includes
moves from a hospital to a nursing home or to home care.
Discharge planning may also include the services of home
health agencies to help with the patient’s home care.”
Centers for Medicare and Medicaid Services, glossary definition www.cms.gov
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3. FOUNDATION OF EFFECTIVE
DISCHARGE PLANNING
– Interdisciplinary team involvement
– Least restrictive environment identified that can meet patient’s needs
– Timely inclusion of patient and/or family in discharge planning process
– Patient and family education about community resources that can help
maintain their maximum potential and independence
– Patient’s benefit plan drives discharge plan, along with choice (for home health
and skilled nursing facilities)
– Safe discharge plan established
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4. WHAT HAPPENS WHEN DISCHARGE
PLANNING IS NOT EFFECTIVE?
– 11.6% of Medicare beneficiaries are re-hospitalized within 30 days of discharge (MEDPAC 2007)
• Results in $15 billion in spending
• Of those readmitted within 30 days, 64% receive no post-acute care between discharge and readmission
- 19% are readmitted within 30 days (New England Journal Of Medicine 2009)
• Only 50% saw physician before their readmission
• As many as 90% of re-hospitalizations within 30 days appear to be unplanned
• Cost estimated to be $17 billion per year (HRET 2011)
- 12.3% readmitted with potentially preventable readmissions (MEDPAC 2011)
– 41% of inpatients leave the hospital with pending test results (Annals of Internal Medicine 2005)
• 66% of physicians are unaware of the results
• 37% of the results are actionable
• 13% of the results are urgent
– 20% of patients experience adverse events after discharge; 75% of those could be prevented (AHRQ)
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7. CMS CONDITIONS OF
PARTICIPATION
Written in 1983
CMS calls them “health and safety standards”
Identified as the foundation for improving quality and
protecting the health and safety of Medicare and
Medicaid beneficiaries
Few changes since 1983 despite changes in the
healthcare industry
2013 Interpretive guidelines and Blue Advisory Boxes
added to CoPs
Screening organizations are to meet or exceed these
standards
Proposed changes to discharge planning section in 2015
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8. FEDERAL REGULATIONS –
SOCIAL SECURITY ACT
§ 1861 (ee)
Discharge Planning Process:
“The Secretary shall develop guidelines and standards for
the discharge planning process in order to ensure a timely
and smooth transition to the most appropriate type of
and setting for post-hospital or rehabilitative care.”
https://www.ssa.gov/OP_Home/ssact/title18/1861.htm
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9. FEDERAL REGULATIONS - SOCIAL
SECURITY ACT § 1861 (ee) (Cont’d)
Discharge Planning Process Standards
Hospitals must:
– Identify at an early stage of hospitalization those
patients in need of discharge planning.
– Provide a discharge planning evaluation for those
identified patients or upon request of patient,
representative or physician.
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10. Discharge Planning Process Standards
Hospitals must:
• Complete evaluation on a timely basis to ensure
appropriate arrangements are in place before
discharge to avoid unnecessary delays in discharge.
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