Discharge Planning from a Hospital or Nursing Home

An important part of hospital or nursing home care involves preparing for the day a patient will leave the facility.

Preparing for discharge is a process that should not be delayed. The most effective preparation begins early and continues until a patient is discharged from a hospital or nursing facility. According to the Center for Medicare & Medicaid Services (CMS), “Medicare participating hospitals must identify patients who need or have requested a discharge plan at the early stage of their hospitalization.” The discharge plan must be “thorough, clear, comprehensive, and understood by hospital staff.”

Either the patient (or the patient’s representative) or a physician can recommend that a post-discharge Plan of Care (POC) be undertaken for the patient. The hospital can then select qualified personnel (such as nurses or social workers) to determine the patient’s continuing needs after discharge from hospital inpatient status. According to CMS, “Depending on the patient’s clinical condition and anticipated length of stay, the discharge planning evaluation should be completed as soon as possible after admission and updated periodically during the patient’s stay.” The plan must be included as part of the patient’s medical record. Formal discharge plans are not required for hospital outpatients.

Regardless of who recommends a discharge plan for a patient, any hospital is required to discuss the planning evaluation with the patient or the patient’s representative. The patient’s input is an important part of the planning process, which should recognize the patient’s authority to make important decisions concerning post-discharge care. As CMS states on page 8 of its booklet Discharge Planning, “The patient should be offered a range of realistic options to consider for post-hospital care.”

According to CMS, these options should take into account:

  • The patient’s capacity for self care
  • The availability of appropriate services and facilities
  • The patient’s preferences
  • The availability, willingness, and ability of family or caregivers to provide care

To people who may benefit from the care and services of Home Health Agencies (HHAs) following discharge, hospitals are required to provide information about HHAs. Patients with discharge plans are entitled to a list of HHAs in their areas. Hospitals cannot recommend any particular Home Health Agencies on a list, but they must provide information about those agencies, including information about any financial ties between an agency and the hospital.

Hospitals are obligated to do more than simply provide information to patients. They are also required to arrange initial implementation of a discharge plan. This includes making arrangements for care that is recommended for the patient and providing adequate information about post-discharge plans to the patient, family members and caregivers, and any providers who will be responsible for the patient’s post-discharge care.

Nursing Homes

The process of requesting a post-discharge Plan of Care for a patient or resident of a long-term care (LTC) nursing facility (NF) or skilled nursing facility (SNF) is very similar to the process required for a POC issued by a hospital.

Nursing homes are required to issue a recommended POC regardless of whether the patient will return home after discharge or be admitted to another nursing facility of any sort. As with hospital POCs, a nursing home discharge plan will include a summary of the patient’s care in the facility he or she is leaving along with information about how the patient’s continuing needs will be met after discharge. Nursing homes must also meet the obligations required of hospitals in providing information to patients and giving consideration to the needs and concerns of patients, family members, and caregivers. As CMS states, nursing facilities are held to the standard of preparing “a post-discharge plan of care (POC), developed with the resident’s and his or her family’s participation. The post-discharge POC assists the resident in adjusting to his or her new living environment.”

Whether a patient is anticipating hospital discharge or discharge from a nursing home, the post-discharge Plan of Care becomes part of the patient’s medical record. If a patient refuses to participate in planning or does not comply with the Plan of Care, that information is entered in the medical record as well. For people anticipating discharge from a hospital or nursing facility, Medicare.gov provides a convenient checklist including key questions to ask in preparing for discharge. The list includes important questions a family member or caregiver ought to consider regarding a patient’s discharge.

Right of Review or Appeal

If you believe a discharge plan calls for you to leave a hospital or nursing facility too early, you may be able to have your case reviewed by an independent reviewer called a Quality Improvement Organization (QIO). If you believe a premature discharge date will compromise your wellbeing, you can learn how to contact the QIO in your state by visiting Medicare.gov or by calling 1-800-MEDICARE. You can also get further information about the appeal process here.

The most effective discharge planning begins early and involves extensive cooperation between a doctor or facility and the patient, who ultimately stands to benefit most from cooperative and ongoing preparation for the important period following discharge. For information about Medicare supplement plans and Medicare Advantage plans designed to save you money, contact MedicareMall today!

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