Part One: Discharge Planning Workshop: Four-Part Webinar Series (ODPT1W5034)-Discharge Planning Workshop, Part One Presentation

Discharge Planning Workshop, Part One Presentation

Pdf Summary

This comprehensive presentation by Laura A. Dixon, Esq., highlights the 2025 updates to the Hospital Conditions of Participation (CoPs) concerning discharge planning for both acute care and critical access hospitals (CAHs). The focus is on patient-centered, goal-oriented discharge processes to improve transitions of care and reduce preventable hospital readmissions.

Key points include:

1. <strong>Discharge Planning Requirements</strong>: Hospitals must have an effective discharge planning process starting at admission that identifies patients at risk for adverse outcomes post-discharge. The plan must incorporate patient goals, treatment preferences, available support networks, and care requirements.

2. <strong>Involvement of Caregivers</strong>: Discharge planning should actively involve patients, caregivers, or support persons, acknowledging their critical role in preventing readmissions and ensuring continuity of care.

3. <strong>IMPACT Act of 2014</strong>: Mandates standardized collection and sharing of post-acute care (PAC) data including functional status, cognitive function, medical conditions, and resource use. Hospitals are required to share relevant data with patients to assist PAC provider selection.

4. <strong>Freedom of Choice</strong>: Patients must be provided a list of Medicare-certified post-acute care providers (home health agencies, skilled nursing facilities, inpatient rehab facilities, long-term care hospitals) and be informed of their freedom to select providers, with any hospital financial interests disclosed.

5. <strong>Documentation and Communication</strong>: Discharge evaluations and plans must be documented in medical records and shared promptly with patients, caregivers, and receiving PAC providers. Transitions must include transfer of all necessary patient information to ensure continuity and safety.

6. <strong>Regular Review and Quality Assurance</strong>: Hospitals and CAHs must periodically assess their discharge planning processes, including reviewing discharge plans of readmitted patients, as part of their Quality Assurance and Performance Improvement (QAPI) programs.

7. <strong>Additional Elements</strong>: New mandates include annual staff training on transfer policies, consideration of social and non-health services (e.g., meals, home modifications), and addressing special populations such as those with mental health or substance use challenges.

The presentation underscores that effective discharge planning reduces readmit rates, improves patient outcomes, and complies with CMS regulatory expectations. Hospitals are encouraged to integrate data tools like CMS’s Care Compare and use evidence-based transition toolkits to optimize their processes.

Keywords

Hospital Conditions of Participation 2025

Discharge Planning Requirements

Acute Care Hospitals

Critical Access Hospitals

Patient-Centered Discharge

IMPACT Act 2014

Post-Acute Care Data

Freedom of Choice in PAC

Documentation and Communication

Quality Assurance in Discharge Planning