Discharge planning rule would give patients a say in follow-up care

CMS is proposing to modernize discharge planning requirements for hospitals and home health agencies. The agency states that the changes would improve quality of care and health outcomes, reduce avoidable complications and readmissions, and allow the requirements to better reflect current practices. The Proposed rule will publish in the Federal Register on November 3, 2015.


The Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) (P.L. 113-185) contains requirements for various health care providers to establish a discharge plan according to each patient’s needs. This Proposed rule would implement these requirements, meant to improve transparency and each beneficiary’s experience while their discharge is being arranged. Each discharge plan must be formed around each patient’s particular goals and preferences. Patients will be consulted as the plan is formed and will have more control over the method of care.


Under the Proposed rule, “hospitals” include inpatient rehabilitation facilities and long-term care hospitals. Hospitals and critical access hospitals would develop a discharge plan within 24 hours of the patient’s admission or registration. The discharge plan would be completed before the patient is sent home or transferred. Plans would need to be completed for all inpatients and some outpatients, such as those at the hospital for observation or undergoing same-day procedures using anesthesia or moderate sedation. Hospitals and critical access hospitals would be required to provide instructions to patients who are sent home, include a medication reconciliation process, and establish a follow-up process after discharge. These facilities, as well as home health agencies, would also have to send specific medical information to the next facility in the event of a transfer.

Patient engagement

The Proposed rule is designed to give patients a stronger voice in their care. CMS emphasizes the rule’s role in giving patients and their caregivers the ability to select high-quality care providers. The providers covered by the rule would be required to share certain quality and resource use data. The CMS Deputy Administrator believes that this rule will help further the Triple Aim of better care, smarter spending, and healthier people.