Take Charge Early: Prevent Unnecessary Readmissions at Admission

CMS Hospital Discharge Planning Rule

What’s the price tag of inadequate discharge planning? For fiscal year (FY) 2018, it’s right around $564 million, according to analysts at the Advisory Board. And that’s just the penalty inflicted for preventable readmissions. Hospitals also have to worry about the costs involved in treating readmitted patients.

Unfortunately, too many people think of discharge planning as an overly simplified process that begins shortly before the patient leaves the facility: Check off all the boxes, and the patient is good to go. And yet, it’s this very mode of thinking that has caused hospitals to be hit with so many readmission penalties.

Make proactive discharge planning a practice in your hospital, says Sue Dill Calloway, in her live webinar with ProfEdOnDemand. During her presentation on smart discharge planning, Calloway lays out ways to comply with both CMS’s rules and the Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) – ways that start when the patient is admitted and don’t end until after the transfer of care.

Rewire Your Thinking about Discharge Planning

To be properly compliant with both CMS and the IMPACT Act, you’ll need to keep 3 instructions in mind:

  • Adhere to CMS’s Discharge Planning Rule and admission assessment requirements
  • Follow certain timelines to adhere to both the IMPACT Act and Discharge Planning Rule, as mentioned in a previous post
  • Discard, as much as possible, the word “discharge” and replace it with “transition.”


Although the first two directives receive the most attention, and are indeed very important, it’s likely that embracing the third will help you make the biggest mindset- and policy-change leap. While “discharge” carries the connotation that you’re relieved of responsibility to the departing patient, “transition” implies that you’re responsible for seeing the patient through the journey to either home care or a skilled nursing facility. It also implies a responsibility to educate the patient on what to do after they leave the hospital, as well as to communicate with those you will be transitioning the patient to after they leave your care.

Not Mincing Words: Although it may seem like a small point, which word you use can have a big impact on how you view the process. Although “discharge” will most likely remain the official word for now, keep “transition” in the back of your mind so you don’t lose sight of your duty: to focus on the patient’s care from the point of admission at your facility to their arrival at their next point of care.

Involve Patients &Caregivers in Planning

To build the most profitable, comprehensive discharge-planning process for each patient, try implementing these steps:

  • Get input from all involved: Ask providers (doctors, nurses, social workers) for recommended courses of action. Survey patients about what they want their care to be. And find out from caregivers what care they’re able to give.
  • Address patients’ fears: After leaving the hospital, patients may be reluctant to seek help for a variety of reasons. Confirm that patients know which warning signs to look for, as well as who to call when they sense something is wrong—or have a question.
  • Coordinate post-discharge care: Before a patient leaves: schedule a follow-up visit with the patient’s primary care physician, ensure medication reconciliation is complete, and educate patients on what to expect after leaving the hospital. According to a 2009 study funded by the Agency for Healthcare Research and Quality (AHRQ), educating patients on post-hospital care from the first moments of hospital stay led to a 30-percent reduction in readmissions or emergency departments post-discharge.
  • Provide patients with materials to help them keep track of their own care, such as this easy-to-follow guide from AHRQ.


Remember: Stay up to date on the latest laws and best practices in discharge planning so that your conversations with departing patients are as productive and effectives as possible. Train staff regularly to ensure this information is always fresh in their minds. Doing so, says Calloway, could mean the difference between a low readmission rate and high CMS penalties.

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