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Discharge Planning News and Proposed Changes

hospital discharge planning

As advocates for our elder loved ones, we need to be particularly aware of the potential risks they face during and after a hospitalization. More attention is being paid to discharge planning and hospital readmissions in recent years and efforts are being made to improve care coordination and discharge planning.

Thanks to Elizabeth E. Hogue, Esq.* who recently shared this news on proposed changes to discharge planning regulations (published November 3, 2015).

Proposed changes in Conditions of Participation (CoPs) for hospitals generally require:
  • Development and implementation of an effective discharge planning process that focuses on patients’ goals and preferences, and prepares patients and their caregivers/support person(s) to be active partners in post-discharge care
  • Planning for care that is consistent with patients’ goals for care and treatment preferences
  • Effective transition of patients from hospitals to post-discharge care
  • Reducing factors leading to preventable hospital readmissions

The proposed regulations require the discharge planning process to be applied to all inpatients, patients under observation status, outpatients undergoing surgery or procedures in which they receive anesthesia or moderate sedation, ER patients identified by discharge planning policies, and any other categories of outpatients recommended by the medical staff/specified in the hospital discharge planning policies.

In addition, hospitals will also be required to do the following:

  • Discharge planning processes must require regular re-evaluation of patients’ conditions to identify changes that require modification of discharge plans. Discharge plans must also be updated on an as-needed basis.
  • Practitioners responsible for patient care must be involved in the ongoing process of establishing patients’ goals of care and treatment preferences.
  • Hospitals must also consider patients’, caregiver/support persons’ and community-based caregivers’ capabilities to perform necessary care.
Specifically hospitals would be required to consider the following when evaluating patients’ discharge planning needs:
  • Admitting diagnosis (or registration reason)
  • Relevant co-morbidities, medical history
  • Anticipated ongoing care needs
  • Readmission risk
  • Relevant psychosocial history
  • Communication needs, including language barriers, diminished hearing and eyesight, and self-reported literacy of patients/ patients’ representatives or caregivers
  • Patients’ access to services and community-based care providers
  • Patients’ goals and preferences

In addition, patients and caregivers must be involved in the development of discharge plans and informed of final plans to prepare them for post-discharge.

Hospitals must also assist patients and their families or representatives to select post-acute providers by using and sharing data on quality measures for home health agencies, nursing facilities, inpatient rehab facilities and long-term care hospitals. Data must be relevant and applicable to patients’ goals and treatment preferences.

Discharge planning evaluations must be documented, completed on a timely basis and included in patients’ medical records. There are a number of specified requirements under these proposed changes, hopefully with positive effects for you as a patient or caregiver. To receive emails from Elizabeth Hogue, Esq. email her at ElizabethHogue(at)

We’ll keep you updated on the latest discharge planning news and tips. For more information about discharge planning check out:

Safe Discharge Planning for Your Elderly Loved Ones
Hospital Discharge Planning Checklist
Reducing Hospital Readmissions: Senior Care in Discharge Planning

Contact our team at 727-447-5845 for questions or assistance with discharge planning and all aspects of aging wisely and well.

Excerpted from information by Elizabeth E. Hogue, Esq., ©2015 Elizabeth E. Hogue, Esq.  All rights reserved.

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