11 Best Practices for Discharge Planning From CMS

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CMS has revised guidelines for the discharge planning condition of participation in the State Operations Manual.

The revisions show the consolidation of 24 previous discharge planning tags into thirteen tags, which were incorporated into the Automated Survey Processing Environment in the summer of 2012. In addition to updated interpretive guidelines, CMS provided advisory practices to improve patient outcomes. While these practices are not required for compliance and will not be cited by surveyors, they may help improve hospitals' discharge planning process, according to CMS.


CMS suggested hospitals implement the following practices:

1. Ensure discharge practices comply with applicable federal civil rights laws and do not lead to needless segregation.

2. Use, on a voluntary basis, an abbreviated post-hospital planning process for certain categories of outpatients, such as patients discharged from observation services, from same-day surgery and for certain categories of emergency department discharges.

3. Develop discharge planning policies and procedures with input from the hospital's medical staff prior to review and approval by the governing body. Also obtain input from patients, patient advocacy groups and other healthcare facilities and professionals who provide care to discharged patients, such as nursing homes and skilled nursing facilities, home health agencies, primary care physicians and clinics.

4. If a patient exercises the right to refuse to participate in discharge planning or to implement a discharge plan, document the refusal in the medical record.

5. Assume every inpatient requires a discharge plan to reduce the risk of adverse health consequences post-discharge and the risk of readmission. Tailor the discharge plan to the needs of the individual patient.

6. Develop collaborative partnerships with post-hospital care providers, including not only skilled nursing facilities and nursing facilities, but also providers of community-based services, to improve transitions of care that might support better patient outcomes.

7. Provide a discharge planning tool to patients and their family or other support persons to help reinforce the discharge plan, encourage patients' participation in developing the plan and provide them an easy-to-follow guide to prepare them for a successful transition from the hospital.

8. Use a multidisciplinary team approach. Team members may include representatives from nursing, case management, social work, medical staff, pharmacy, physical therapy, occupational therapy, respiratory therapy, dietary and other healthcare professionals involved with the patient's care.

9. Consider taking the following actions to improve the patient's post-discharge care transition:
•    Schedule follow-up appointments with the patient's primary care physician or practitioner and in-home providers of service as applicable.
•    Fill prescriptions prior to discharge.
•    If applicable, arrange remote monitoring technologies, such as pulse oximetry and daily weights for congestive heart failure patients, pulse and blood pressure monitoring for cardiac patients and blood glucose levels for diabetic patients.
•    Follow up with phone calls to the patient within 24 to 72 hours after discharge.

10. Refer patients and their families to the Nursing Home Compare and Home Health Compare websites and other resources for additional information regarding Medicare-certified skilled nursing facilities and home health agencies, as well as Medicaid-participating nursing facilities.

11. Schedule follow-up appointments for ambulatory care services prior to discharge to reduce the likelihood of a preventable readmission.

More Articles on Discharge Planning:

Care Coordination Demands Streamlined Communication Beyond Hospital Walls
12 Lessons on Caregiver Engagement in Care Transitions

9 Actions to Take During Post-Discharge Follow-Up Calls

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