CMS recently issued a final rule on discharge planning requirements for hospitals, critical access hospitals (“CAHs”), and home health agencies (“HHAs”). The new regulations focus on the exchange of patient information between healthcare facilities in the discharge process. The final rule allows health care facilities more flexibility in the discharge planning process than the proposed rule provided. The final rule includes the following requirements:

  • Supplying Patient With Access to Information About Post-Acute Care (“PAC”) Facilities: Hospitals will be required to share with patients important quality measures and resource-use measures of PAC facilities that may be pertinent to patient decision-making. The measures to be reported may include the incidence of major falls that lead to patient injury and the number of readmissions back to the hospital following discharge.
  • Providing Patients With a List of PAC Facility Options: As part of the discharge planning process, hospitals must provide to patients a list of potential facilities that could provide the PAC services needed by a patient, including HHAs, skilled nursing facilities, long-term acute care hospitals, and inpatient rehabilitation facilities. The final regulations did not define a geographic region within which to report all potential PAC facilities and is intended to provide the patient with more information to help in selecting a facility in addition to the quality metrics.
  • Transferring All Necessary Medical Information: At discharge, a hospital must also transfer all necessary medical information to the appropriate PAC facility, including the patient’s course of treatment, post-discharge care goals, and treatment preferences. The final regulations did not adopt a regimented data set of specific medical information that must be transferred and also did not mandate a timeframe in which the medical information must be sent. This will allow more flexibility in determining what information to transmit, and hospitals will be required to make this information available to PAC facilities upon discharge when it is needed in order to continue appropriate patient care.
  • Identifying Appropriate Post-Hospital Services: The discharge planning process must include an evaluation of the patient’s likely need for appropriate post-hospital services including hospice care services and extended care services. Hospitals must also evaluate the potential need for home health services, non-health care services, and community-based care providers. This evaluation must also determine the availability of the appropriate services as well as the patient’s access to those services.
  • Allowing for Patient Access to Medical Records: Upon oral or written request from patients, hospitals will be required at discharge to provide patients with access to their medical records in electronic format or, if not available electronically, in a readable hard copy form as agreed to between the facility and its patients.