Part Two: Discharge Planning Workshop: Four-Part Webinar Series (ODPT2W5034)-Discharge Planning Workshop Series, Part 2 Presentation

Discharge Planning Workshop Series, Part 2 Presentation

Pdf Summary

This comprehensive webinar on case management discharge planning in acute care hospitals, led by Toni Cesta and Bev Cunningham, focuses on regulatory requirements, assessments, and best practices aligned with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP), specifically 42 C.F.R. Part 482. The core discharge planning rule (482.43) mandates hospitals to identify early those patients at risk for adverse health outcomes post-discharge, conduct timely discharge planning evaluations by qualified personnel (e.g., RNs, social workers), and create discharge plans incorporating patient preferences, resource availability, and quality data from post-acute care providers including home health agencies (HHA), skilled nursing facilities (SNF), inpatient rehabilitation facilities (IRF), and long-term care hospitals (LTCH).<br /><br />Hospitals must provide patients with Medicare-participating post-acute care options relevant to their geographic area, disclose any financial interests in providers, and enable informed patient choice. Annual staff training and written policies for safe patient transfers are required by July 2025. The discharge planning process must include ongoing reassessment, especially when clinical or social conditions change, and regular review of discharge plans, emphasizing prevention of 30-day readmissions by identifying root causes and gaps in care transitions.<br /><br />Social determinants of health (SDOH) and psychosocial factors are integral to assessing discharge needs. Social work plays a critical role in evaluating social drivers such as housing instability, food insecurity, mental health, and safety concerns, utilizing standardized screening tools approved by CMS (e.g., AHC, PRAPARE) to identify health-related social needs (HRSNs). Reporting on SDOH impacts reimbursement and quality scores starting with mandatory CY 2026 reporting. Z codes (Z55-Z65) document socioeconomic and psychosocial factors affecting health outcomes.<br /><br />Additional federal regulations addressed include the IMPACT Act, NOTICE Act, PASRR screening for mental health needs in nursing facility placements, and discharge appeal rights notices (IMM). Hospitals must comply with payer-specific utilization management and appeal requirements.<br /><br />The presentation includes practical case management tools such as standardized assessment forms capturing demographics, living arrangements, readmission risks, social work and home care referral criteria, and psychosocial evaluations to ensure comprehensive, patient-centered discharge planning that supports successful transitions and reduces readmissions.

Keywords

case management

discharge planning

acute care hospitals

CMS Conditions of Participation

42 C.F.R. Part 482

post-acute care providers

social determinants of health

psychosocial factors

readmission prevention

IMPACT Act