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Discharge Planning News


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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Problematic Transitions of Care: Elderly Hospital Discharge & Readmissions


Everyone looks forward to being able to return to the comforts of home after being hospitalized. However, too many patients will quickly return, especially those over age 65 and with multiple conditions.


Nearly 18 percent of Medicare patients are readmitted to a hospital within 30 days of discharge, and patients with multiple chronic conditions are readmitted at rates as high as 25 percent, according to Medicare Payment Advisory Commission (MedPAC) estimates.

Within 90 days of hospital discharge, as many as 35% of Medicare recipients will be readmitted to the hospital.

Those at highest risk have certain conditions such as heart failure, COPD (Chronic Obstructive Pulmonary Disease), Psychoses, Intestinal Problems or recent surgery; those taking 6 or more medications; and those being discharged on weekends or holidays. Older patients who live alone were twice as likely to be readmitted if they did not have supportive community services such as home care.


Research on care transitions suggests that as many as 20 to 30 percent of adverse events following discharge are preventable, and another 30 percent could be minimized/improved.

“Decentralized responsibility is a central defect of the discharge process”, says Judith Black, M.D., MHA, medical director of senior products at Highmark Blue Cross Blue Shield. After a hip replacement, for example, an orthopedic surgeon writes orders, a primary care physician writes orders, and a case manager issues instructions. Patients are often confused and overwhelmed by the process, and even family caregivers often find they do not receive much communication or feel they understand the process.

Communication problems are thus one primary causes of problems after discharge. In a study published by the Journal of Hospital Medicine, more than half of patients over age 70 years responding to a post hospitalization telephone survey did not recall anyone talking with them about how to care for themselves after hospitalization. Poor communication and follow up care lead to issues like medication errors, falls, infections and dehydration. Even when communication is good, patients are often groggy, medicated and overwhelmed. This is why it can be vital to have an advocate there to hear the instructions, ask questions and answer the patient’s questions later. Written instructions in laymen’s terms help as well.

Lack of good follow-up care and supportive services is another cause of preventable readmissions. Studies have indicated that 40-50% of readmissions are linked to lack of community services/follow-up care. For patients in the 85+ age range, more than half require assistance with daily needs in the period following hospitalization. Family caregivers may not be prepared to care for a loved one who needs more physical assistance in a weakened state. The logistics of staying with someone while they are weak or on heavy medication and handling other responsibilities may be too much. Patients without local family support need coordinated services after they leave the hospital such as help with activities of daily living, household help, meal preparation, medication management, physical therapy, transportation to appointments.


Our sister company, EasyLiving, Inc. provides Pinellas County home care support services such as personal care (help with bathing, dressing, grooming), household help, medication management, transportation and a special Transitions of Care Program to help immediately after hospital discharge.

Aging Wisely’s patient advocate care managers can help with the hospital discharge process, ensuring a smooth transition for you or your loved one. We invite you to review our article on elder patient advocacy and contact us today for help.

Look for our future articles on solutions for hospital discharge problems, including a checklist of things you can do, resources, and ways to be prepared.

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