Changes to Discharge Plan Requirements Still in the Works at CMS

CMS Discharge Planning

Proposed adjustments to the Medicare conditions of participation (CoPs) for discharge planning could mean 2018 will be much different for case management departments in hospitals, home care agencies and other healthcare facilities that work on discharge planning.

Those changes, said Toni G. Cesta, owner of Case Management Concepts, will affect RN case manager and social worker workloads, and family caregivers and physicians will have to be moved involved in creating discharge plans than in the past.

Cesta will detail the current and proposed discharge planning requirements in a conference for ProfEdOnDemand, “The CMS Discharge Planning Rules for 2018.” Cesta will also cover the best ways for case management directors, finance directors, case managers, directors of patient-centered medical homes, home care directors, and nursing directors to evaluate the effectiveness of a discharge planning program, transition patients across the continuum of care, and ensure that a facility’s discharge department is ready and able to meet the new changes.

Hospital Discharges Too Often Leave Patients in the Dark

One consequence of the Affordable Care Act is that hospitals are held partly accountable for the care of Medicare patients after they are discharged, noted the National Law Review. But that discharge is often not accompanied with information on the quality of care discharged patients could receive.

A Health Affairs study from 2017 found that, upon discharge, most patients received “only lists of skilled nursing facilities from hospital staff members, while staff members reported not sharing data about facilities’ quality with patients because they believed that patient choice regulations precluded them from doing so.” That means, the study concluded, that patient choices were usually not based on data. That could be part of the reason behind a rise in post-discharge hospital revisits.

A study released last summer found that, particularly among Medicare beneficiaries age 65 and older, hospital revisits were up. “Hospital revisits are common after discharge from observation stays, frequently result in inpatient hospitalizations, and have increased over time among Medicare beneficiaries,” the authors wrote in the British Medical Journal.

CMS’s Proposed Changes Put Pressure Back on Care Facilities

CMS says its proposed changes, which would revise the discharge planning requirements that hospitals, long term care and inpatient rehab facilities, critical access hospitals, and home health agencies would need to meet in order to participate in the Medicare and Medicaid programs, are aimed at meeting the challenge of preventing readmissions. The proposed rule would also implement the discharge planning requirements of the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act).

The IMPACT Act’s requirement that these providers take into account quality measures and resource use measures should better assist patients and their families during the discharge planning process and encourage them to become more active participants in the planning of their care, according to the proposed rule.

Those quality measures cover the following domains, according to CMS:

  • Skin integrity and changes in skin integrity
  • Functional status, cognitive function, and changes in function and cognitive function
  • Medication reconciliation
  • Incidence of major falls
  • Transfer of health information and care preferences when an individual transitions


The resource use measure domains include:

  • Resource use measures, including total estimated Medicare spending per beneficiary
  • Discharge to community
  • All-condition risk-adjusted potentially preventable hospital readmissions rates
Be Ready for the Changes!

Join Cesta in her conference, where she discusses how to evaluate your current discharge planning process and review strategies for safely transitioning your patients across the continuum of care. In addition she reviews how you can engage other members of the interdisciplinary care team in the process of planning for the patient’s movement across the continuum including verbal and written hand-off communications. She also covers the positive impact that effective discharge planning processes can have on hospitals, post-acute providers and patients.

To join the conference or see a replay, order a DVD or transcript, or read more

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