The New Discharge Planning Rule: What You Need to Know

CMS has announced a new discharge planning rule to improve care transitions by defining discharge requirements for hospitals and Home Health Agencies (HHAs). Ultimately, the goal is to reduce readmissions and adverse events by complementing and aligning with interoperability efforts across the continuum. The rule also gives patients greater ability to access their medical records and participate in the discharge planning process by requiring hospitals to share information about post-acute care provider performance. The rule’s effective date is 11/29/2019.

What You Need to Know:

  1. Hospitals must have an effective discharge planning process that focuses on patient goals and treatment preferences, and includes the patient as well as his or her caregivers/support person(s) as active partners in planning for post-discharge care. Note the process is not prescribed in the rule.
  2. Patients can request a copy of their medical record, including the discharge plan from the hospital, in their requested form and format. The hospital must comply with the patient’s access request. Similar requirements exist for HHAs and CAHs.
  3. Hospitals need to assist patients, their families, or their caregivers/support persons in selecting a PAC 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.
  4. 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. They must also provide a discharge planning evaluation for those patients so identified, as well as for others upon the request of the patient, patient’s representative, or the patient’s physician.
  5. The HHA-specific CoP final rule requires that HHAs communicate with all relevant parties, including physicians who are involved in the patient’s HHA plan of care, whenever there are revisions related to the plan for patient discharge.

How PatientPing Helps:

Here are three important ways in which PatientPing can help your organization with these new requirements:

  1. Hospitals are expected to give patients the option to return to the same HHA from which they received services prior to their hospitalization.
    • Our Stories product provides details about prior HHA services and allows for compliant referral options.
  2. Hospitals are required to produce discharge plans for patients at risk for adverse events.
    • Our patient flags, visit histories, and diagnosis information supports hospital teams in assessing a patient’s likelihood of experiencing adverse events.
  3. Hospitals must equip patients with the information they need to make an informed decision regarding post-acute care.
    • With increased transparency on performance and quality metrics, post-acute providers have an added incentive to improve. PatientPing can help PACs improve care quality with the help of Pings, visit histories, program attribution details, and patient flags, to help increase referral volume and quality scores.

To learn more about the discharge planning rule check out the CMS fact sheet.