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Changes to Discharge Planning Final Rule in a Nutshell

By Cynthia Raymond, Clinical Nurse Manager

Updates to the Discharge Planning Final Rule have been in effect as of November 29, 2019.  

The Discharge Planning Final Rule applies to acute care hospitals and specialty facilities such as long-term care hospitals (LTCHs), inpatient rehabilitation facilities, inpatient psychiatric facilities, children’s hospitals, cancer hospitals (IRFs), critical access hospitals (CAHs) and home health agencies (HHAs).  In order to be eligible to participate in Medicare and Medicaid programs, facilities must meet the Final Rule’s requirements.

Under the Final Rule, facilities must assist patients with the selection of post-acute care (PAC) service providers by using post-acute care data on quality and resource-use measures.  This data must align with the patients’ goals of care and treatment preferences.  Providers are required to have specific documentation in the medical record regarding this data and the patients’ post-acute care options.

Regarding access to medical records, the rule states that patients have the right to access their medical records in the format that they desire, if that format is readily producible.  If the requested format is not readily producible then the facility must provide a readable hard copy to the patient.

Under the Final Rule the discharge planning process must be effective, focus on the patient’s goals and treatment preferences, and include the patient’s caregivers or designated representatives in the planning of post-acute care (PAC).  The establishment of an effective discharge planning process must ensure that the discharge plan provides a safe and effective transition to post-acute care (PAC) and reduce the risk factors that lead to subsequent readmissions to the hospital.

Other aspects of the discharge planning process under the Final Rule that were modified include:

  • All discharge planning assessments must be developed or supervised by a registered nurse, social worker or other qualified personnel; the original rule did not indicate who was responsible for developing the assessment.
  • The plan must be updated with any changes to a patient’s condition that would affect the discharge plan.  The original rule did not address changes to the patient’s condition regarding the impact these changes would have on the discharge planning process.
  • Facilities must have an effective discharge plan.  The plan must focus on the patient’s goals and treatment preferences and it must include the patient and/or representative in the process of planning for post-acute care (PAC).  The plan must also provide a safe and effective transition to post-acute care and reduce the risk factors leading to readmissions to the hospital.
  • Discharge planning assessments must be done on a timely basis to warrant that post-acute care arrangements will be made prior to discharge, avoiding unnecessary delays to the discharge process.  The original rule required that the discharge plan be developed within 24 hours of admission and completed before the patient was discharged home or transferred to another facility.

The Final Rule requires that upon transfer to another facility, the hospital must provide all necessary medical information that is pertinent to the current course of illness, treatment, post-discharge goals and treatment preferences to those providers responsible for post-acute care (PAC), along with the providers responsible for follow-up care of the patient.

CBIZ recommends that if your organization is affected by these changes that a review of the discharge planning process should be performed to confirm that your organization is in compliance with the updated rule. 

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