CMS’ Discharge Planning Rule Supports Interoperability and Patient Preferences

The Centers for Medicare & Medicaid Services (CMS) today issued a final rule that empowers patients to make informed decisions about their care as they are discharged from acute care into post-acute care (PAC), a process called “discharge planning.” In addition to improving quality by improving these care transitions, today’s rule supports CMS’ interoperability efforts by promoting the seamless exchange of patient information between health care settings, and ensuring that a patient’s health care information follows them after discharge from a hospital or PAC provider.

The final rule revises hospital discharge planning requirements for long-term care hospitals (LTCHs) and inpatient rehabilitation facilities, inpatient psychiatric facilities, children’s hospitals, cancer hospitals, (IRFs), critical access hospitals (CAHs), and home health agencies (HHAs). Each of these facilities must meet these requirements as a condition to participate in Medicare and Medicaid programs. Among other things, it requires the discharge planning process to focus on the patient’s goals of care and treatment preferences. Additionally, the final rule revises the hospital patient’s rights and the facility’s requirements regarding a patient’s access to their medical records.

Final changes to hospital, CAH, and HHA requirements

Under the final rule, hospitals, CAHs, and HHAs would be required to:

• New discharge planning requirements, as mandated by the IMPACT act for hospitals, HHAs, and CAHs, that requires facilities to assist patients, their families, or the patient’s representative in selecting a post-acute care (PAC) services provider or supplier by using and sharing PAC data on quality measures and resource use measures. This data must be relevant and applicable to the patient’s goals of care and treatment preferences.
  
• New discharge planning process requirements for CAHs and HHAs (such requirements did not exist before). Revised language that now requires a hospital (or CAH) to discharge the patient, and also transfer or refer the patient where applicable, along with his or her necessary medical information (current course of illness and treatment, post-discharge goals of care, and treatment preferences), at the time of discharge, to not only the appropriate post-acute care service providers and suppliers, facilities, agencies, but also to other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care.
  
• Revised compliance language for HHAs that now requires these facilities to send all necessary medical information (current course of illness and treatment, post-discharge goals of care, and treatment preferences), to the receiving facility or health care practitioner to ensure the safe and effective transition of care, and that the HHA must comply with requests made by the receiving facility or health care practitioner for additional clinical information necessary for treatment of the patient.
  
• New requirement that sends necessary medical information to the receiving facility or appropriate PAC provider (including the practitioner responsible for the patient’s follow-up care) after a patient is discharged from the hospital or transferred to another PAC provider or, for HHAs, another HHA.
  
• Hospitals must ensure and support patients’ rights to access their medical records in the form and format requested by the patient, if it is readily producible in such form and format (including in an electronic form or format when such medical records are maintained electronically).

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