Every hospital that accepts Medicare and Medicaid must comply with the CMS discharge planning guidelines. These standards must be followed for all patients and not just Medicare or Medicaid. CMS published changes to the discharge planning standards in February 2020 but has yet to publish revised interpretive guidelines and survey procedures to match the new regulations.

This program will briefly discuss the Impact Act and how it affects hospital discharge planning. It requires hospitals to assess a patient at admission, using standardized information to assist patients with post-discharge care such as home health, skilled nursing facilities, long term care hospitals and inpatient rehab facilities. Information on all four must be provided to the patients except for Critical Access Hospitals. Medical records must include the discharge planning process, discharge instructions, discharge planning requirements. This program will address transfers to other facilities, assessment of readmissions within 30 days, caregiver rights and recommendations, reduction of factors that lead to preventable readmissions, timely discharge planning, and more.

Discharge Planning Conditions of participation for Critical Access hospitals will be discussed briefly. Those regulations follow the Acute hospitals requirements.

Learning Objectives:

• Discuss the CMS has revised the discharge planning requirements that apply to all hospitals and critical access hospitals
• Recall patients and physicians can request a discharge planning evaluation
• Discuss that information about the hospitalization must be provided to the physician or provider before the first post hospital visit
• Describe that the patient has a right to get medical records timely including a copy of their discharge plan

Areas Covered in the Session:

• Introduction
• Deficiency data for discharge planning
• Discharge planning process and the IMPACT Act
• Identification of patients needing discharge planning
• Role of support person
• Incapacitated patient
• Discharge planning process
• RN, social worker, or qualified person to develop evaluation
• Timely evaluation
• Discussion of evaluation with patient or individual acting on their behalf
• Discharge evaluation in the medical record
• Documentation of the discharge process
• Discharge plan
• Physician request for discharge planning
• Implementation of the patient’s discharge plan
• Reassessment of the discharge plan
• Freedom of choice for post-acute care providers
• Transfer or referral
• Critical Access Hospital Discharge planning requirements
• Appendix and Resources
• Live Q&A session

Attendees:

• Discharge Planners
• Transitional Care Nurses
• Social Workers
• All Staff Nurses who Discharge Patients in a Hospital Setting
• Chief Nursing Officer
• Nurse Educators
• Chief Operation Officer
• Chief Medical Officers
• Physicians
• Risk Managers
• Regulatory/Compliance Officer
• Chief Executive Officer
• Nurse Managers
• PI Director
• Health Information Director
• Patient Safety Officer
• Any Person Serving on a Hospital Committee to Redesign the Discharge Process to Prevent Unnecessary Readmissions