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Many healthcare institutions are required to provide discharge planning for their Medicare patients as part of their “Conditions of Participation” in the Medicare program.  Under the Medicare program, discharge planning services are required for hospital inpatients, long-term care hospital and rehabilitation inpatients, skilled nursing facility residents, patients in swing-beds, and hospice patients.  Discharge planning services may include:

  • Helping a beneficiary and his or her family and friends think through the beneficiary’s needs in the care setting to which he or she is transitioning;
  • Determining whether the beneficiary will need help managing medications;
  • Determining whether the beneficiary will need a visiting nurse or therapy services, such as physical therapy, occupational therapy, or speech therapy;
  • Considering whether the beneficiary will need home health aides to assist with bathing, dressing, or preparing meals;
  • Determining if the beneficiary will need assistance with obtaining and paying for necessary medications;
  • Determining whether the beneficiary will need community services, such as transportation to various activities such as appointments with medical providers, getting to events such as religious services or recreational activities;
  • Considering whether the beneficiary will need assistance in managing his or her financial and legal affairs;
  • Considering if the beneficiary will need assistance in understanding their rights under the Medicare, Medicaid, and Older Americans Act programs. 

Unfortunately, actually having the identified discharge services arranged and delivered remains a problem.  The discharge planner is supposed to make sure the required services are reasonably available in the beneficiary’s community and that the beneficiary and family/friends are aware of the options.  It is far less clear that the services have to actually be set up with quality providers before patients are discharged. All too often, beneficiaries end up in poor quality settings too far from their community, or needed home health services are not in place.  Medicare beneficiaries should work with their primary care doctor, long term care ombudsman and community outreach programs, along with their discharge planners, to ensure quality transition care is arranged.

For more information on discharge planning: (site visited July 6, 2015); see also (Site visited July 6, 2015) ; Revision to State Operations Manual (SOM), Hospital Appendix A -Interpretive Guidelines for 42 CFR 482.43, Discharge Planning, available at (site visited July 6, 2015).

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