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Proposed revisions to discharge planning requirements would mandate patient and caregiver involvement

November 17th, 2015 | Posted in Consumer Focus, Quality Care, Recent Posts | Tagged


You have a chance to comment on CMS’ latest attempt to improve discharge planning at hospitals and help patients avoid unnecessary and costly readmissions.

In what acting CMS Administrator Andy Slavitt promises is a “simple but key change,” CMS is proposing to modify discharge planning Conditions of Participation for hospitals and home health agencies, with a goal of making them making them more patient-centered.

The revisions would require more cooperation between hospitals, post-acute care facilities and home health agencies, and include requirements to develop a patient’s discharge plan within 24-hours of admission or registration, establish a post-discharge follow-up process, and send specific medical information to a facility receiving a patient, according to the announcement.

One key change would require hospitals and practitioners specifically to involve the patient and patient caregivers in the development of the discharge plan. Until now, this had only been a CMS expectation.

The discharge plan would also have to address the patient’s goals of care and treatment preferences, and document those in the medical record.

In addition, hospitals and home health agencies would be required to assist patients, their families and caregivers in selecting any post-acute care providers, including using or sharing data on quality measures on those providers, and would have to ensure that the data is “relevant and applicable to the patient’s goals of care and treatment preferences.” CMS would also expect a hospital to document in the patient’s record that the data was shared with the patient and used during the discharge planning process.

CMS is accepting public comment on the proposed rule until Jan. 4, 2016. To read the proposal and how to comment, go to — A.J. Plunkett (