LeadingAge Washington

5/28/13

CMS Issues Survey Guidance Re: Hospital Discharge Planning

Citing expectations for collaboration with post-discharge providers, including HCBS and housing, to enhance care transitions and partnerships, the new CMS Survey letter can be found here.  For an overview of the findings, read below. 

·      Revisions update the guidance for the hospital discharge planning Condition of Participation (CoP), including expectations for outreach and/or communication with post-acute care settings [emphasis added].

·        Advisory Boxes:  Included throughout the guidelines are “blue boxes” that “…display advisory practices to promote better patient outcomes….” The advisory boxes provide resource information and/or references for process improvement, but do not comprise required practice and are not used for determining compliance.  Blue Box e.g.s, include:

“For Information – Not Required/Not to be Cited

It would be advisable for the hospital to develop its discharge planning policies and procedures with input from the hospital’s medical staff prior to review and approval by the governing body. Hospitals are also encouraged to obtain input from:

·        Other healthcare facilities and professionals who provide care to discharged patients, including but not limited to: nursing homes/skilled nursing facilities, home health agencies, primary care physicians and clinics, etc.; and

·        Patients and patient advocacy groups.

For Information– Not Required/Not to be Cited

·        Although not required under the regulations, hospitals would be well advised to develop collaborative partnerships with post-hospital care providers to improve care transitions of care that might support better patient outcomes. This includes not only skilled nursing facilities and nursing facilities, but also providers of community-based services. For example, Centers for Independent Living (CIL) and Aging and Disability Resource Centers (ADRC) are resources for community-based services and housing available to persons with disabilities and older adults….”

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