Every hospital that accepts Medicare and Medicaid must comply with the CMS discharge planning guidelines. These standards must be followed for all patients and not just Medicare or Medicaid. CMS published changes to the discharge planning standards in February 2020, but has yet to publish revised interpretive guidelines and survey procedures to match the new regulations.

This program will briefly discuss the Impact Act and how it affects hospital discharge planning. It requires standardized assessment, quality data, and resource data requirements. It requires hospitals to assist patients with post-discharge care such as home health, skilled nursing facilities, long-term care hospitals, and inpatient rehab facilities. Information on all four must be provided to the patients, except for Critical Access Hospitals.

Patients have a right to timely access to their medical records, which must include the discharge planning process, discharge instructions, and discharge planning requirements. This program will address transfers to other facilities, assessment of readmission within 30 days, caregiver rights and recommendations, reduction of factors that lead to preventable readmissions, timely discharge planning, and more.
Discharge Planning Conditions of participation for Critical Access hospitals will be discussed briefly. Those regulations follow the Acute hospital's requirements.

Learning Objectives:-

• Discuss that CMS has revised the discharge planning requirements that apply to all hospitals and critical access hospitals
• Recall that patients and physicians can request a discharge planning evaluation
• Discuss that information about the hospitalization must be provided to the physician or provider before the first post-hospital visit
• Describe that the patient has a right to get medical records in a timely including a copy of their discharge plan

Agenda:-

• Introduction
• Deficiency data for discharge planning
• Discharge planning process and the IMPACT Act
• Identification of patients needing discharge planning
• Role of a support person
• Incapacitated patient
• Discharge planning process
• RN, social worker, or qualified person to develop the evaluation
• Timely evaluation
• Discussion of evaluation with the patient or the individual acting on their behalf
• Discharge evaluation in the medical record
• Documentation of the discharge process
• Discharge plan
• Physician's request for discharge planning
• Implementation of the patient’s discharge plan
• Reassessment of the discharge plan
• Freedom of choice for post-acute care providers
• Transfer or referral
• Critical Access Hospital Discharge Planning Requirements
• Discharge planning metrics

Appendix and Resources

Who Will Benefit?

• Discharge planners
• Transitional care nurses
• Social workers
• All staff nurses who discharge patients in a hospital setting
• Chief nursing officer
• Nurse educators
• Chief operation officer
• Chief medical officers
• Physicians
• Risk managers
• Regulatory/Compliance officer
• Chief executive officer
• Nurse managers
• PI director
• Health information director
• Patient safety officer
• Any person serving on a hospital committee to redesign the discharge process to prevent unnecessary readmissions.