The Centers for Medicare & Medicaid Services has revised the provider certification manual for hospitals, giving more in-depth guidelines around discharge planning. The goal is for hospitals to reduce readmissions by partnering with post-acute providers.
The update was made to the State Operations Manual, Hospital Appendix A.
Discharge planning evaluations should assess whether a patient’s post-discharge needs can be met in his or her next environment, such as a skilled nursing facility, the revision states. The evaluation also should consider whether the patient’s insurance would cover needed services in the next care setting. A discharge plan based on the evaluation must be developed and placed in the patient’s medical record in a timely fashion, the guidelines say.
The hospital is responsible for initial implementation of this discharge plan, including arranging the transfer, and providing information to the patient about the goal of treatment in the next setting. The revised guidelines also include new information about the requirement to give patients with skilled nursing needs a list of potential SNFs. Hospitals must disclose certain financial interests in these nursing homes.
The guidelines include a bulleted list of medical information that the hospital must give to the next care provider, such as a copy of the patient’s advanced directive, if there is one.
Blue boxes in the revised manual contain suggested best practices for discharge planning. Surveyors are not to cite hospitals for failing to adopt these practices. One suggestion is for hospitals to obtain input from SNFs and other post-acute providers when developing discharge planning policies and procedures.
In a separate action, CMS invited comments from nursing homes about feeding assistant reporting requirements. Providers have until June 17 to submit feedback about the requirement to keep a record of all paid feeding assistants.