Summary of CMS Final Rule


Final Rule on Discharge Planning, Interoperability and Patient Preferences

Summary at a Glance

On September 30, CMS published a final rule which:

  1. Revises hospital discharge planning requirements for hospitals and post-acute care (PAC) providers (long-term care hospitals (LTCHs) and inpatient rehabilitation facilities (IRFs), inpatient psychiatric facilities, children’s hospitals, cancer hospitals, critical access hospitals (CAHs), and home health agencies (HHAs)). The changes in the discharge planning process also impact non-PAC providers such as hospices, assisted living facilities and other community organizations.
  2. Promotes the continuous exchange of patient information between health care settings to guarantee a patient’s health care information follows them after discharge from a hospital or Post-Acute Care (PAC) provider.
  3. Requires the discharge planning process to focus on the patient’s goals of care and treatment preferences; and revises the hospital patient’s rights and the facility’s requirements regarding a patient’s access to their medical records.

* * *

According to CMS, the final rule “puts patients in the driver’s seat of their care transitions and improves quality by requiring hospitals to provide patients access to information about PAC provider choices, including performance on important quality measures and resource-use measures.”

Changes to Hospital, CAH, and HHA requirements:

Under the final rule, hospitals, CAHs, and HHAs would be required to:

  • Establish new discharge planning requirements, as mandated by the IMPACT Act for hospitals, HHAs, and CAHs, that requires facilities to assist patients, their families, or the patient’s representative in selecting a post-acute care (PAC) services provider or supplier by using and sharing PAC data on quality measures and resource use measures. This data must be relevant and applicable to the patient’s goals of care and treatment preferences.
  • Establish new discharge planning process requirements for CAHs and HHAs (such requirements did not exist before). Revised language now requires a hospital (or CAH) to discharge the patient, and also transfer or refer the patient where applicable, along with his or her necessary medical information (current course of illness and treatment, post-discharge goals of care, and treatment preferences), at the time of discharge, to not only the appropriate post-acute care service providers and suppliers, facilities, agencies, but also to other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care, including hospice providers.
  • Revise compliance language for HHAs that now requires these facilities to send all necessary medical information (current course of illness and treatment, post-discharge goals of care, and treatment preferences), to the receiving facility or health care practitioner to ensure the safe and effective transition of care, and that the HHA must comply with requests made by the receiving facility or health care practitioner for additional clinical information necessary for treatment of the patient.
  • Establish a new requirement that sends necessary medical information to the receiving facility or appropriate PAC provider (including the practitioner responsible for the patient’s follow-up care) after a patient is discharged from the hospital or transferred to another PAC provider or, for HHAs, another HHA.
  • Ensure that hospitals support patients’ rights to access their medical records in the form and format requested by the patient, if it is readily producible in such form and format (including in an electronic form or format when such medical records are maintained electronically).

Access the Federal Register publication of the Final Rule on September 30

The impact of this Final Rule for Hospices:

Even though hospice is not included as a PAC in the final rule, hospice is still a provider of care. Hospices will receive and send necessary medical information as indicated for patient continuity of care.

In their discharge planning process, hospitals must focus on the patient’s goals of care and treatment preferences, which would include hospice care. Hospitals may assist patients in accessing hospice CMS publicly reported quality measures and data as part of their discharge planning process and resources to meet goals of care and treatment preferences.

With the final rule requirements regarding access to their medical records, patients may also request the same from hospices.

Members should consider reviewing the following:

  1. Agency process and practices regarding receiving and sending patient information with other care providers.
  2. Policies, procedures, and practices regarding patient involvement in the care planning process and access to their medical records.
  3. Provider preview reports and CMS Hospice Compare scores for accuracy.

Members should direct questions to regulatory@nhpco.org.




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