On November 3, 2015, the Centers for Medicare and Medicaid Services published proposed regulations governing discharge planning by home health agencies in the Federal Register. If finalized, these proposed regulations will require agencies to devote considerably more time and resources to discharge planning activities. Comments to these proposed regulations are due sixty days from the date of publication in the Federal Register.
CMS proposes to add a Condition of Participation (CoP) for discharge planning. This new CoP will generally require agencies to develop and implement an effective discharge planning process that focuses on preparing patients to be active partners in post-discharge care, to provide effective transitions of patients from home health agencies to post-home health agency care and to reduce factors leading to preventable readmissions. Specifically, agencies' discharge planning process will have to ensure that discharge goals, preferences and needs of each patient are identified and result in development of a discharge plan for each patient.
If the proposed regulations are finalized, agencies' discharge planning process must require regular re-evaluations of patients to identify changes that require modification of discharge plans consistent with existing provisions for updating patient assessments. Discharge plans must be updated, as needed, to reflect these changes.
Physicians responsible for home health plans of care must be involved in the ongoing process of establishing appropriate discharge plans.
As part of the process of developing appropriate discharge plans for each patient, agencies will be required to consider caregiver/support person availability and patients' or caregivers' capabilities to perform required care as part of the identification of discharge needs.
Agencies will also be required to involve patients and caregivers in the development of discharge plans and inform them of final discharge plans. Final discharge plans must address patients' goals of care and treatment preferences.
If patients are transferred to another home health agency or are discharged to a skilled nursing facility (SNF), inpatient rehab facility (IRF) or Long-Term Care Hospital (LTCH), agencies must assist patients and their caregivers to select a post-acute care provider by using and sharing data that includes, but is not limited to, home health agency, SNF, IRF or LTCH data on quality measures and data on resources use measures. Agencies must also ensure that post-acute care data on quality measures and data on resource use measures is relevant and applicable to patients' goals of care and treatment preferences.
In addition, agencies will be required to evaluate patients' discharge needs and document discharge plans on a timely basis based on patients' goals, preferences and needs. Discharge plans must be included in clinical records. The proposed regulation will also require agencies to discuss the results of evaluations with patients or patients' representatives. All relevant patient information must be incorporated into discharge plans in order to facilitate its implementation and to avoid unnecessary delays in patients' discharge or transfer.
Finally, agencies will be required to send necessary medical information to receiving facilities or practitioners which must include:
If finalized as proposed, these regulations will certainly require agencies to dedicate considerable additional resources to discharge planning activities. Stay tuned for more information!
©2015 Elizabeth E. Hogue, Esq. All rights reserved. Reprinted in Home Care Technology Report by permission of the author. Further reproduction, in whole or in part, prohibited without author's permission. elizabethhogue@elizabethhogue.net