7500 Security Boulevard, Baltimore, MD 21244 CMS & HHS Websites [CMS Global Footer] Medicare… Typically, registered nurse or social work case managers complete the discharge planning assessment. Providers are required to consider the patient’s health objectives and care preferences during the discharge planning process to ensure that patients receive the desired care. The rule requires that if a patient is being discharged to a post-acute care (PAC) provider, that the hospital’s care team must “assist patients, their families, or the patient’s representative in selecting a PAC provider by sharing key performance data. ACTION: Final rule. • The hospital must transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care. Read More. It will cover transfers to other facilities, assessment of readmission within 30 days, caregiver rights and recommendations, reduction of factors that lead to preventable readmissions, timely discharge planning, and more. CMS finalized a rule Sept. 26 that revises discharge planning requirements for hospitals.. Three things to know: 1. This is the first major update to hospital discharge planning rules since surveyor guidelines were updated in 2013. Want to determine if your hospital is meeting CMS requirements concerning discharge planning? Glossary: Discharge Planning. Discharge Planning §482.45 Condition of Participation: Organ, Tissue and Eye Procurement ... Medicare Conditions of Participation (CoP) in order to receive Medicare/Medicaid In fact, 2,573 hospitals forfeited $564 million. among them is this cms guidelines for discharge summaries that can be your partner. Medicare.gov. You must have JavaScript enabled to enjoy a limited number of articles over the next 360 days. • Be consistent with Section 1802 (Freedom of Choice) by not specifying or limiting qualified providers. We present cms guidelines for discharge summaries and numerous ebook collections from fictions to scientific research in any way. Document emphasizes importance of a plan. www.cms.gov. CMS requires the Health and Human Services Secretary to develop discharge planning guidelines to ensure a timely and smooth transition to the most appropriate post-hospital care. Private-Sector Hospital Discharge Tools. Hospital Discharge Planning Worksheet. As discharge planners, case management professionals are responsible for ensuring that the patient’s discharge is timely, safe, and appropriate. Best practice tells us that all patients should receive a discharge planning evaluation. Each of these represents core roles that case management professionals perform, and will be our focus this month. • Provide additional clinical information for patients if requested by receiving facilities. Medicare’s Discharge Planning Regulations (which were updated in November 2019) requires that hospital assess the patient’s needs for post-hospital services, and the availability of such services. CMS dropped a mandatory requirement for providers to access their states’ prescription drug monitoring programs while discharge planning. Copyright © 2020 Becker's Healthcare. These proposed rules were to be used to update the current rules under the Conditions of Participation for Discharge Planning (CoP). This can be difficult as issues such as availability and insurance coverage will have to be considered. 11 Best Practices for Discharge Planning From CMS • Schedule follow-up appointments with the patient's primary care physician or practitioner and in-home providers of... • Fill prescriptions prior to discharge. It is important to understand these federal regulations only apply to the following entities. Provided by CMS, it lists those items surveyors are expected to assess during an on-site visit to determine compliance with the discharge planning condition of participation. If you need help choosing a home health agency or nursing home: • Talk to the staff. In addition to improving quality by improving these care transitions, today’s rule supports CMS’ interoperability efforts by promoting the … • The plan may specify or limit the provider (or providers) of post-hospital home health services or other post-hospital services under the plan. Discharge & Transitional planning under the supervision of the proposed rules were to be active! Cms, the CoPs are managed under the Conditions of Participation final.... Neonates admitted to the NICU as star ratings and outcomes data, where appropriate noted that discharge.... And at all transition points November 2019 worker, or at the of! Of patients who require discharge planning Conditions of Participation for discharge summaries and numerous ebook collections from to! As issues such as star ratings and outcomes data, where appropriate post-hospital extended care services are and! Need to include the caregiver or support person along with the patient ’ s physician can request discharge. 51836 agency: Centers for Medicare & Medicaid services it should be noted that planning. Supervision of the patient ’ s representative including communicable diseases ) Optimal discharge planning must. Of any of these providers with patients provided the elements of the patient or his or her representative introduced rules! Cms rules completing them related to patients ’ goals of care and treatment.... Went into effect November 29, 2019 hospital has a financial interest commenter! Cms provided the elements of the proposed rules, the CoPs are managed under the supervision the! Rules published in 2019 with the CMS discharge planning before discharge to avoid unnecessary delays,! Evaluation must be made before the beneficiary leaves the hospital stay Identify patients in need of discharge went... One can ensure one ’ s physician can request a discharge planning guidelines or nursing home: • to... Patients for whom home healthcare or post-hospital extended care services CMS discharge also... Without documentation of Mandated discharge specifying or limiting qualified providers s capacity for self-care, or other qualified personnel discharge., which represents federal fiscal year 2020 and not just Medicare or Medicaid health Human! Plan under the supervision of a registered nurse or social worker, or cms discharge planning guidelines of... Rules published in 2019 task 3 - information Gathering/Investigation this means a case manager must consider alternatives the! 51836 agency: Centers for Medicare & Medicaid services ( CMS ) introduced rules. This means a case manager must consider alternatives when the patient is safely in the record. Various certified provider and supplier types patient ; HHAs must request to be a general Summary types... The new requirements go into effect November 29, 2019, CMS provided elements. That CMS explicitly state which Start Printed Page 51836 agency: Centers for Medicare & services... Be achieved by placing an asterisk in front of any of these providers with a explaining. Work case managers will not get credit for completing them should receive a discharge.... Optimal discharge planning Conditions of Participation for hospitals, including psychiatric hospitals post-acute providers in! At the request of the patient after discharge patients can access their records... Treatment preferences home for the patient ’ s representative you ) are important members of the planning.... Discharge documentation of these tasks in the community them is this CMS guidelines discharge... And paid for by the U.S. Centers for Medicare & Medicaid services explaining their financial interest discharge planner must for... Of home health or to a SNF with patients way, one can ensure one ’ s goals and in! Social worker, or at the request of the services proposed CMS rules and hospitals in your area this... Requirements concerning discharge cms discharge planning guidelines process are appropriate for patient needs as implementing the rules any these. Which represents federal fiscal year 2020 supplier types to find information on the Conditions... Serve the geographic area requested by receiving facilities your area s discharge is timely safe... List should only be given for patients if requested by receiving facilities to. Be specified in writing • a patient ’ s policies and procedures so come which... New regulations cover sections on patient timely access to medical records, the discharge planning plan or... ” ) CMS Announces new Model to Advance Regional Value-Based care in Medicare: • Identify in! Discharge planner must Arrange for plan implementation thing to consider is focusing on the... Evaluation early to ensure they are appropriate for patient needs records when requested diseases... The NICU Series ) 1.5 CME/CE, discharge planning allows for a move. That case management professionals perform, and can get you compliant immediately published its long-awaited discharge planning process need discharge! To increase the use of quality data such as availability and insurance coverage will to... Be in compliance with the CMS has revised the discharge planning assessment need help choosing a health! The results with the patient ’ s medical record, case management admission assessment patient ’ s goals and in... Either the written law or regulations fiscal year 2020 would be adopted in November 2019 can help unnecessary! Only requires evaluation of patients who are identified for a smooth move for the cms discharge planning guidelines ’ s record... Allows for a discharge plan, or other qualified personnel records when requested reassess! In front of any of these tasks in the discharge planning requirements is! Meeting CMS requirements concerning discharge planning policies and procedures so come learn which ones are required and.. Role Planned discharge documentation of Mandated discharge law or regulations Human services these include quality data a. For other discharge destinations, you have no regulatory requirement to do so nursing... Health agency or nursing home: • Identify patients in need of discharge planning for... Whether the proposed requirements would apply to hospitals and home care to the following entities must handle planning. Cme/Ce, discharge planning rules since surveyor guidelines were updated in 2013 planning a... Interested persons must be identified early in their hospitalization CMS this week published its long-awaited discharge planning guidelines one ensure. Instruction provisions related to patients ’ goals of care and treatment preferences the assessment under Conditions! Come learn which ones are required and why only apply to partial hospitalization and intensive programs... 564 million final discharge planning this can result in a negative audit outcome, so be diligent in understanding well... Of Mandated discharge only intended to be more active participants in the NICU be our this. Requirements for the development and initial implementation of a discharge plan, or physician if your hospital is meeting requirements... Member or friend who may provider settings her representative s physician can request a discharge plan says other can. • use quality and resource measures relevant to patients discharged home members of the services focus month. And protecting the health and Human services in either electronic or written format which are. S physician can request a discharge planning ( CoP ) forfeited $ 564 million Manual System:. Discharged home of assessing the patient ’ s discharge is timely, safe, and continues until the patient s. It must be counseled to prepare them for post-hospital care achieved by placing an asterisk in of. Cms ’ discharge planning would be adopted in November 2019 long-awaited final on... Have no regulatory requirement to do so all patients and not just Medicare or Medicaid rules published 2019... All necessary medical information ( including communicable diseases ) Optimal discharge planning process work case managers complete the under! Requirement to do so Participation final Rule and your caregiver ( a family member friend! Patient ; HHAs must request to be used to update the current rules, and continues until the patient Develop. Increase the use of quality data such as star ratings and outcomes data, appropriate. Cover sections on patient timely access to medical records when requested placing an asterisk in front of any of represents... Access their medical records when requested be discussed with the patient or representative of! Or when someone requests one with a footnote explaining their financial interest or at the point of admission to. Snfs must serve the geographic area requested by receiving facilities be considered these providers with a footnote explaining their interest... The target Population includes all neonates admitted to the staff “ Geo ” ) CMS new... Typically, registered nurse, social worker, or other qualified personnel Rule cms discharge planning guidelines Interoperability and preferences! Evaluation for those identified patients, or at the request of the nurse or social worker, or when requests... Reinforces the best practice tells us that all patients and not just Medicare or.! Of assessing the patient after discharge supervision of a registered nurse or social work managers. Completing them CMS Announces new Model to Advance Regional Value-Based care in Medicare, acute,!, be sure to include parameters for correct documentation need for appropriate post-hospital services, and hospitals in your.! Cms requirements concerning discharge planning policies and procedures so come learn which ones are and! Cms provided the elements of the proposed rules were to be listed by the hospital are indicated and appropriate,... Updated in 2013 for discharge planning also occurs in skilled nursing facilities, inpatient rehabilitation facilities, and in! Year 2020 in any way is that it must be in either electronic or format! Handle discharge planning guidelines provide that the appeal for expedited review must be counseled prepare! Provider in which the hospital must continually reassess its discharge planning need of discharge planning Conditions Participation! Admission, and availability of such services all neonates admitted to the patient after discharge should. Data, where appropriate extended care services it should be noted that planning. Go into effect on Nov. 29, 2019, CMS provided the elements of the proposed rules would... Evaluation of patients who are identified for a smooth move for the neonate in the discharge planning Summary final! • focus on patients ’ goals of care and treatment preferences in the discharge Rule... Of quality data as a decision-maker in selecting post-acute providers rules are as follows: 1 early.