discharge planning booklet icn908184

8/10/2019 Discharge Planning Booklet ICN908184

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DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Medicare & Medicaid Services

Discharge Planning

ICN 908184 October 2013


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This booklet was current at the time it was published or uploaded ontothe web. Medicare policy changes frequently so links to the sourcedocuments have been provided within the document for your reference.

This booklet was prepared as a service to the public and is not intended

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Discharge Planning 2

ACUTE CARE HOSPITALS, INPATIENT REHABILITATION FACILITIES (IRF),AND LONG TERM CARE HOSPITALS (LTCH)

Acute care hospitals provide acute hospital inpatient care to the patient. Theaverage length of stay (LOS) for acute care hospitals is 2 3 days. IRFs

and LTCHs provide post-acute care to the patient. The average LOS forIRFs is 13 days and for LTCHs it is 25 days.

Discharge

Planning

Process

When you is used in this chart, we are referring toacute care hospitals/post-acute care facilities.

An acute care hospital/post-acute care facilitypatients plan of care includes information aboutdischarge planning activities and a dischargeplanning evaluation.

Discharge planning involves:

Determining the appropriate post-hospitaldischarge destination for a patient;

Identifying what the patient requires for asmooth and safe transition from the acutecare hospital/post-acute care facility to hisor her discharge destination; and

Beginning the process of meeting the patientsidentied post-discharge needs.

When the discharge planning process iswell executed, and there are no unavoidablecomplications or unrelated illnesses or injuries, thepatient may continue progressing toward the goals ofhis or her plan of care after discharge.


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ACUTE CARE HOSPITALS, INPATIENT REHABILITATION FACILITIES (IRF),AND LONG TERM CARE HOSPITALS (LTCH) (continued)

Discharge

PlanningProcess

Medicare-participating acute care hospitals/post-acute

care facilities must identify patients who need or haverequested a discharge plan at an early stage of theirhospitalization. The discharge planning process mustbe thorough, clear, comprehensive, and understoodby acute care hospital/post-acute care facility staff.

The physician may make the nal decision as towhether a discharge plan is necessary. If a physicianrequests a discharge plan, you must develop suchplan, even if the interdisciplinary team determines thatit is not necessary (as applicable).

Depending on the patients needs, discharge planningmay be completed by personnel in multiple disciplineswho have specic expertise. You may designatedischarge planning responsibilities to appropriatequalied personnel such as registered nurses,social workers, or other qualied personnel. Theseindividuals should have:

Discharge planning experience;

Knowledge of social and physical factors thataffect functional status at discharge; and

Knowledge of appropriate community servicesand facilities that can meet the patientspost-discharge clinical and social needs.


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Discharge

PlanningEvaluation

Unless you develop a discharge planning evaluation

for every patient, you must have a process to notifypatients, patients representatives, and attendingphysicians that they may request an evaluation.You must also convey that the discharge planningevaluation will be completed upon request.

The discharge planning evaluation determines thepatients continuing care needs after he or she leavesthe acute care hospital/post-acute care facility setting.Appropriate qualied personnel must completedischarge planning evaluations:

For every patient who is identied at potentialrisk of adverse health consequences without adischarge plan; and

If the patient, the patients representative, or theattending physician requests such evaluation.

Depending on the patients clinical condition andanticipated LOS, you should complete the dischargeplanning evaluation as soon as possible after

admission and update it periodically during thepatients stay.

You must include the discharge planning evaluation inthe patients clinical record. It considers the patientscare needs immediately upon discharge and whetherthe needs are expected to remain constant or lessenover time. The discharge planning evaluation identiesappropriate after-acute care hospital/post-acute care


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Discharge

PlanningEvaluation

If the patient was admitted from a facility

(such as a NF or SNF) and he or she wishesto return to the facility, whether it has thecapability to provide the patients after-acutecare hospital/post-acute care facility carerequirements;

Information obtained from the patient andfamily/caregivers (such as nancial andinsurance coverage); and

The patients and family/caregiversunderstanding of the patients discharge needs.

Discharge

Planning

You must discuss results of the discharge planningevaluation with the patient or the individual acting onhis or her behalf. You should offer the patient a rangeof realistic options to consider for after-acute carehospital/post-acute care facility care, depending on:

The patients capacity for self-care;

The availability of appropriate services and

facilities;

The patients preferences, as applicable; and

The availability, willingness, and ability of family/caregivers to provide care.


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Discharge

Planning

If you develop and maintain a list of HHAs and SNFs

to provide to the patient, you must update such listsat least annually. The lists must include informationabout HHAs and SNFs in which you have adisclosable nancial interest and HHAs and SNFs thathave such an interest in you. You may also providea list of HHAs in the geographic area in which thepatient resides from Home Health Compare locatedat http://www.medicare.gov/homehealthcompareora list of SNFs in the geographic area that the patientrequests from Nursing Home Compare located at

http://www.medicare.gov/nursinghomecompareon theCenters for Medicare & Medicaid Services website.

You must arrange initial implementation of thedischarge plan, which includes:

Arranging necessary after-acute care hospital/post-acute care facility services and care,including transfer to facilities (such asrehabilitation hospitals) and referrals (such asmedical equipment suppliers, community

resources, and HHAs). Arrangements mayinclude necessary medical information such asbrief reason for hospitalization, principaldiagnosis, and hospital course of treatment. If thepatient is being transferred to another inpatientor residential health care facility, the informationmust accompany the patient to the facility. If the
http://www.medicare.gov/homehealthcomparehttp://www.medicare.gov/nursinghomecomparehttp://www.medicare.gov/nursinghomecomparehttp://www.medicare.gov/homehealthcompare


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Discharge

Planning

patient is being referred for follow-up ambulatory

care, the information should be transmitted to thepatients physician within 7 days after dischargeor before the rst appointment for ambulatoryservices, whichever occurs rst. If the physicianis unable to accept the information electronically,you may instruct the patient to provide it to thephysician at the next appointment; and

Educating the patient, family/caregivers,and community providers about the patientsafter-acute care hospital/post-acute care facility

care plans. Individuals who will be providingcare should know and be able to demonstrate orverbalize the patients care needs. You shouldprovide the patient and family/caregivers withinformation and written and verbal instructionsin preparation for the patients after-acute carehospital/post-acute care facility care, including:

Post-discharge options;

What to expect after discharge; and

What to do if concerns, issues, or problemsarise.


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Discharge

Planning

You must ensure that the patient receives proper

post-discharge care within the constraints of yourauthority under State law and within the limits of apatients right to refuse discharge planning services.

You must document the following in the patientsclinical record:

Discharge planning evaluation activities;

That discharge planning evaluation results werediscussed with the patient and family/caregivers;

That the patient refused to participate indischarge planning or comply with a dischargeplan, as applicable;

That a list of HHAs or SNFs was provided to thepatient or an individual acting on the patientsbehalf, as appropriate if such services areneeded; and

That you attempted to arrange after-acute carehospital or post-acute care facility care witha HHA or SNF, as applicable, that meets the

patients or familys expressed preference. Ifsuch arrangements could not be made, includethe reason(s) they could not be made.


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Discharge

PlanningReassessment

The Quality Assessment and Performance

Improvement Program must include a mechanismfor ongoing reassessment of its discharge planningprocess through review of discharge plans in closedclinical records. This reassessment determineswhether the discharge planning process wasresponsive to patients post-discharge needs.


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HOME HEALTH AGENCIES (HHA)

HHAs provide Home Health care to the patient with certain care needsand who meets program requirements.

Discharge

SummaryWhen you is used in this chart, we are referring toHHAs.

The HHA discharge summary must include thepatients medical and health status at discharge. Itmay be incorporated into routine summary reportsfurnished to the physician.

You should document the discharge summary in thepatients clinical record.

A physicians order is not required to discharge thepatient unless you have such policy or it is requiredby State law. You should document in the patientsclinical record that the physician was notied of thedischarge. You must inform the attending physicianthat the discharge summary is available and send it tohim or her upon request.


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HOSPICES

If certain conditions are met, the Medicare Hospice benet providesHospice services for the palliation and management of a patientsterminal illness and related conditions.

Discharge

Planning

Process

When you is used in this chart, we are referring toHospices.

You must have a discharge planning process in placethat takes into account the prospect that the patientscondition might stabilize or otherwise change suchthat he or she cannot continue to be certied asterminally ill.

The discharge planning process must include planningfor any necessary family counseling, patient education,or other services before the patient is dischargedbecause he or she is no longer terminally ill.

Discharge

SummaryPrior to discharging the patient, you must obtain awritten physicians discharge order from the Hospicemedical director. If the patient has an attendingphysician involved in his or her care, this physician

should be consulted before discharge. The attendingphysicians review and decision should be included inthe discharge summary.


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HOSPICES (continued)

Discharge

SummaryThe Hospice discharge summary must include:

A summary of the patients stay, including

treatments, symptoms, and pain management;

The patients current plan of care;

The patients latest physician orders; and

Any other documentation that will assist inpost-discharge continuity of care or is requestedby the attending physician or receiving facility.

The discharge summary should be documented in thepatients clinical record.

If the care of a patient is transferred to anotherMedicare- or Medicaid-certied facility, you mustforward a copy of the following to the receiving facility:

The Hospice discharge summary; and

The patients clinical record, if requested.

If a patient revokes the election of Hospice care or isdischarged from Hospice, you must forward a copy ofthe following to the patients attending physician:

The Hospice discharge summary; and

The patients clinical record, if requested.


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INPATIENT PSYCHIATRIC FACILITIES (IPF)

IPFs, which are classied as psychiatric hospitals or psychiatricunits, provide the patient with acute psychiatric treatment that can bereasonably expected to improve his or her condition.

Discharge

PlanningWhen you is used in this chart, we are referring toIPFs.

The IPF discharge planning process includesconsideration of:

The discharge alternatives addressed in thepsychosocial and behavioral health assessment;and

The extent to which the goals in the treatmentplan have been met.

The patient and all relevant professionals in eachservice caring for the patient should participate in thisprocess.

The discharge planning process should addressanticipated problems after discharge and suggestedmeans for intervention, including:

Accessibility and availability of communityresources and support systems, includingtransportation; and

Special needs related to the patients functionalability to participate in aftercare planning.


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INPATIENT PSYCHIATRIC FACILITIES (IPF) (continued)

Discharge

SummaryYou should complete the IPF discharge summarywithin a reasonable timeframe and provide:

A recapitulation of the patients hospitalization;

A summary of the patients condition ondischarge; and

Recommendations for appropriate services forfollow-up or aftercare.

The discharge summary must include:

The reasons for the patients admission to theIPF;

Nursing and health care providers notes (suchas social workers);

A plan that outlines psychiatric, medical, andphysical treatment and medication modalities, asapplicable;

A list of medication records;

Documentation that the patient receivedelectroconvulsive therapy, if such treatment was

provided; Documentation that the patient was in seclusion

or physically restrained, if such use wasperformed;

Evidence of the patients and familys responseto treatment interventions;


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LONG TERM CARE (LTC) FACILITIES

LTC Facilities, also known as Nursing Facilities (NF) or Skilled NursingFacilities (SNF), are primarily engaged in providing the resident witheither skilled nursing care and related services or rehabilitation services

(based on his or her needs).

Discharge

PlanningWhen you is used in this chart, we are referring toLTC Facilities.

You must complete discharge planning whenyou anticipate discharging a resident to a privateresidence, another NF or SNF, or another type ofresidential facility. Discharge planning includes:

Assessing the residents continuing care needs,including:

Consideration of the residents andfamily/caregivers preferences for care;

How services will be accessed; and

How care should be coordinated amongmultiple caregivers, as applicable;

Developing a plan designed to ensure thatthe residents needs will be met after discharge

from the facility, including resident andfamily/caregiver education needs; and

Assisting the resident and family/caregiversin locating and coordinating post-dischargeservices.


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LONG TERM CARE (LTC) FACILITIES (continued)

Discharge

SummaryThe LTC Facility discharge summary must include:

A recapitulation of the residents stay;

A nal summary of the residents status atthe time of discharge. This summary will beavailable for release to authorized individualsand agencies, with the consent of the resident orthe residents legal representative; and

A post-discharge plan of care (POC), developedwith the residents and his or her familysparticipation. The post-discharge POC assiststhe resident in adjusting to his or her new living

environment.

You should document the discharge summary in theresidents clinical record.


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SWING BEDS

Swing beds are hospitals, as dened in Section 1861(e) of the SocialSecurity Act, or Critical Access Hospitals (CAH) with a Medicare provideragreement that includes Centers for Medicare & Medicaid Services

approval to provide swing bed services, that may use their beds asneeded to provide the patient with either acute or Skilled NursingFacility-level care.

Discharge

PlanningWhen you is used in this chart, we are referring tohospitals or CAHs.

You must complete discharge planning when youanticipate discharging a patient from a Swing Bed.Discharge planning includes:

Assessing the patients continuing care needs,including:

Consideration of the patients andfamily/caregivers preferences for care;

How services will be accessed; and

How care should be coordinated amongmultiple caregivers, as applicable;

Developing a plan designed to ensure that the

patients needs will be met after discharge fromthe facility, including patient and family/caregivereducation needs; and

Assisting the patient and family/caregiversin locating and coordinating post-dischargeservices.


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SWING BEDS (continued)

Discharge

SummaryThe discharge summary must include:

A recapitulation of the patients stay;

A nal summary of the patients status atthe time of discharge. This summary will beavailable for release to authorized individualsand agencies, with the consent of the patient orthe patients legal representative; and

A post-discharge plan of care (POC), developedwith the patients and his or her familysparticipation. The post-discharge POC assiststhe patient in adjusting to his or her new living

environment.

You should document the discharge summary in thepatients clinical record.


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