New Guidance Issued for Hospital Discharge Planning as Part of the Effort to Reduce Hospital Readmissions

CMS recently updated its guidance to state surveyors on reviewing a hospital’s discharge planning process. Although the requirements for the discharge planning process did not change much, there is a new emphasis on the process by which hospitals determine that a patient will need a discharge plan, especially if the hospital does not provide a discharge plan for every patient. Hospitals must inform patients that they may request a discharge plan and may participate in the planning process.  CMS’ new emphasis on discharge planning is one attempt to help hospitals reduce readmission rates and increase savings.

Application to All Patients

Federal regulations at 42 C.F.R. 482.43 require hospitals to have a discharge planning process that applies to all patients. Discharge planning does not apply only to Medicare inpatients, but all patients both inpatients and outpatients at the hospital. The hospital must  screen all of its patients to determine which patients will require a full discharge plan to meet their health goals. The criteria used for the screening process is to be documented by the hospital. The initial screening is to be  conducted early in the patient’s hospitalization. Ideally CMS says the evaluation is to be made when a patient is admitted or shortly thereafter. The guidance says that no citation should be issued unless the assessment of a likely need for discharge planning was made within 48 hours of discharge or the discharge was delayed to complete the assessment.

Planning for Transition

Discharge plans must be made by the hospital if the patient or his or her representative physician requests it. The guidance requires hospitals to inform patients that they can request a discharge plan.  Patients or their representatives are to be included in the discharge planning process.  CMS believes that this is essential to determine whether the patient will be safe at home or has adequate assistance from family or friends who can provide care.

The guidance further states that “hospitals are expected to have knowledge of the capabilities and capacities of not only the long-term care facilities, but also the various types of service providers in the area where most of the patients it serves receive post-hospital care, in order to develop a discharge plan that not only meets the patient’s needs in theory, but can also be implemented.” The concern is that hospitals discharge patients to facilities such as skilled nursing facilities  (SNF) that only send the patient back to the hospital’s emergency department when they cannot provide care to the patient. As part of the discharge planning process, the guidance has hospitals assess whether the care provided after the patient is discharged will be sufficient.

Reduction in Readmissions

A group in Minnesota just issued a report showing how effectively discharge planning can reduce readmissions. Participants in the Reducing Avoidable Readmissions Effectively (RARE)  campaign in Minnesota took credit for preventing 4,570 hospital readmissions from January 1, 2011 to December 31, 2012. Participants in RARE concentrated on comprehensive discharge planning, patient and family engagement, transition care support, and transitions communication. RARE stated that their efforts over the two-year period  resulted in reducing health care expenditures by $40 million in Minnesota  and allowed people to spend 18,820 nights in their own bed instead of in a hospital, SNF or some other institution.  Eighty-three hospitals and 93 community partners across Minnesota participated in the RARE campaign.

A study published in the New England Journal of Medicine in 2009 showed that 19.6 percent of all Medicare fee-for-service beneficiaries were readmitted within 30 days of discharge, and 34 percent within 60 days of discharge. CMS says in the guidance, “when the discharge planning  process is well executed, and absent unavoidable complications or unrelated illness or injury, the patient continues to progress towards the goals of his or her plan of care after discharge.” The guidance continued, “reducing the number of preventable hospital readmission is a major priority for patient safety, and holding hospitals accountable for complying with the discharge planning CoP [conditions of participation] is one key element of an overall strategy for reducing readmissions.”

The guidance was issued as a memorandum to state survey agencies, accompanied by an advance release of revisions to Appendix A to the State Operations Manual, which contains survey protocols and conditions of participation regulations for hospitals.