On May 17, the Centers for Medicare & Medicaid Services issued Revision to State Operations Manual (SOM), Hospital Appendix A – Interpretive Guidelines for 42 CFR 482.43, Discharge Planning, which is available online here.
Although the major focus of revisions is to consolidate the prior twenty-four discharge planning tags into thirteen, the guidelines emphasize the importance of appropriate hospital discharge planning to ensure smooth transitions. Additionally, consideration of pre-hospital setting, patient participation on the process, and patient choice are emphasized.
CMS published a final rule in August 2004, as mandated by the Balanced Budget Act of 1997, requiring hospitals to inform patients of their choice in home health agencies (HHA) and to disclose any financial interests in home health agencies. Under the rule, hospitals must provide all appropriate patients with a list of available Medicare participating HHAs that serve each patient’s area of residence. The list must include all HHAs that request to be included and may be constructed by the hospital or as available through Home Health Compare. Hospital developed lists must be updated annually.
Although the revised Interpretive Guidelines (IG) do not change hospital discharge requirements, this article will serve as an overview of major elements of them.
Hospital Discharge Planning Requirements
Hospitals are required to carry out discharge planning functions for all inpatients. Discharge planning is a four-stage process:
- Evaluation of post-discharge needs
- Development of a discharge plan
- Initiation of the discharge plan
Hospitals may develop a discharge plan of all patients or, in accord with policy, develop a plan for those identified as likely to need discharge planning. Once screening is carried out and person identified as needing discharge planning, a more detailed evaluation of functional status and needs is conducted. This evaluation must include identification of available family and caregivers, community resources, traditional health care services (e.g. home health, hospice, therapy, dialysis, etc.) and nontraditional services such as those for environmental modification, transportation, meals and household services. Persons who cannot receive required care in the community must be screened for appropriate inpatient settings.
Hospitals are required to provide discharge planning by or under the supervision of a nurse or social worker or other appropriately trained person. Patients or their representatives must be actively engaged in the development of the discharge plan, which must incorporate patient’s goals and preferences. Once needed services are identified, the hospital is required to arrange for the initial implementation of the discharge plan. In addition, education, written discharge instructions, provision of supplies needed immediately post-discharge, and a list of all medications are required. Necessary medical information must also be sent to providers to whom patients have been referred. Additional information should include diagnoses and reason for hospitalization, condition on discharge, allergies, pending lab work, advance directive information, follow-up appointments, and referrals.
Required Provision of List of HHAs
In accord with the regulation requiring hospitals to include in the discharge plan a list of HHAs that request to be on the list (as well as skilled nursing facilities) that are available to the patient. The list must be presented to all patients for whom home health services are indicated. According to the IG, the hospital must inform the patient or family of their freedom of choice among participating Medicare providers and, “when possible, respect patient and family preferences when they are expressed.” Further, “the hospital must not specify or otherwise limit the qualified providers that are available to the patient.” Finally, the discharge plan must identify any disclosable financial interest a hospital has with an HHA or HHA has with a hospital.