The memo, released June 6, identified information that hospitals frequently fail to share with post-acute care referral partners. The lack of information can put patients at risk of harm and “can cause avoidable readmissions, complications and other adverse events.”
“When a patient is discharged from a hospital, it is important to provide their post-acute provider and caregivers as applicable with the appropriate patient information related to a patient’s treatment and condition in order to decrease the risk of readmission or an adverse event,” the CMS says.
Here are the five most common areas of missing information identified by CMS:
- Patients with serious mental illness, complex behavioral needs, and/or substance use disorder and treatments implemented to manage these conditions.
- Incomplete lists of medications prescribed during or prior to a patient’s hospital stay.
- Information related to any wounds, such as pressure ulcers, bruising or lacerations and the durable equipment used in treatment.
- Patients preferences and goals for care.
- A patient’s needs at home or what home environments may affect their health after discharge from a skilled nursing facility.
CMS requires hospitals to “have an effective discharge planning process that focuses on the patient’s goals and treatment preferences” and are required to refer patients to post-acute care with “all necessary medical information pertaining to the patient’s current course of illness and treatment.”
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