CMS provides in-depth guidance on discharge planning

The Centers for Medicare & Medicaid Service has revised its guidance on discharge planning, offering hospitals in-depth guidelines to help promote better patient care outcomes and reduce readmissions.

The revisions were published Friday in the State Operations Manual (SOM), Hospital Appendix.

The guidelines state hospitals are responsible for initial implementation of the discharge plan, including arranging the transfer to the next setting, such as a skilled nursing facility, and providing the patient with information about treatment goals in that setting. The new guidelines encourage greater communication among healthcare professionals, facilities, patients and support staff in an effort to reduce readmissions.

"It is not uncommon in the current healthcare environment for patients to be discharged from inpatient hospital settings only to be readmitted within a short timeframe for a related condition," the new guidance states. "Some readmissions may not be avoidable. Some may be avoidable, but are due to factors beyond the control of the hospital that discharged the patient. On the other hand, a poor discharge planning process may slow or complicate the patient's recovery, may lead to readmission to a hospital, or may even result in the patient's death."

The guidance cited analysis of Medicare claims data for a two-year period that found nearly 20 percent of Medicare fee-for-service beneficiaries were readmitted within 30 days of discharge and 34 percent within 60 days of discharge. Approximately 70 percent of surgical patients readmitted within 30 days had a medical cause for the readmission. Ten percent of readmissions were planned, according to the analysis.

Recent research indicates hospitals also can reduce readmissions by coordinating patient care with emergency department care managers and viewing medical history through health information exchanges.

To learn more:
- read the new guidance (.pdf)
- read the analysis

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