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December 23, 2015

Filing code for submitting comments: CMS-3317-P

Dear Sir or Madam:

Comments on the Proposed Discharge Planning Rule as put forth by the Centers for Medicare & Medicaid Services (CMS)

The Center for Medicare Advocacy (the Center) is pleased to comment on the November 3, 2015, proposed revisions to the discharge planning regulations of CMS as published in the Federal Register (80 Fed. Reg. 68126).  The proposed revisions address discharge planning requirements for Medicare-participating hospitals, Critical Access Hospitals (CAHs), and Home Health Agencies (HHAs).

The Center appreciates the design of the proposed rule changes and its focus on reducing avoidable hospital readmissions and improving patient care, with particular attention to the psychiatric and behavioral health needs of patients, including substance abuse disorders.  We also appreciate that the proposed rule calls for coordination, consultation, and the use of information from community-based service providers in aid of comprehensive discharge planning that is safe and well-coordinated.  The features of this CMS proposal appropriately recognize the importance of the “Improving Medicare Post-Acute Care Transformation Act of 2014” (the Impact Act of 2014), Pub. L. 113-185.  Overall, we appreciate the comprehensive approach taken by CMS in developing its discharge planning proposed rule.

The Center has long promoted comprehensive discharge planning.  The Center has also been concerned that discharge planning has not been used comprehensively as a tool to promote the health and well-being of Medicare beneficiaries as they move from one care setting to another.  In its efforts to promote comprehensive discharge planning, the Center has held conferences, provided panel discussions, written advocacy materials, provided training to a variety of professional groups, and participated in CMS work groups on

discharge planning, including reviewing drafts of CMS’ discharge planning pamphlets over the years.  In addition, the Center has joined with the Consumer Coalition for Health Care and the National Academy of Elder Law Attorneys in advocating for comprehensive discharge planning. The Center has also written widely on the topic.  See the Center’s materials on discharge planning for beneficiaries and for advocates at

The Center is pleased that the CMS proposed rule fits within the framework of existing Medicare discharge planning guidance and regulations for hospitals (42 CFR §482.43) and is applicable to all inpatients (see also Section 1861(e) of the Social Security Act (42 U.S.C. §1395x (ee)); for Skilled Nursing Facilities (SNFs) (42 CFR §§483.12 – admission and discharge) and 483.20 (resident assessment); for Home Health Agencies (HHAs) (oral and written notice about when Medicare will pay for services, including changes in one’s condition (42 CFR §484.10), and for hospice (42 CFR §428.26(d)).

Our areas of concern about discharge planning include:

  1. That the quality and timeliness of notice to individual beneficiaries about a suggested or pending discharge is given great consideration; that all discharge plans must be safe and orderly and based on patient assessment and patient involvement.
  2. That the quality of the translation of the content of notices about discharge planning must be clear and presented in languages appropriate to a particular beneficiary.
  3. That careful consideration of the needs of persons with disabilities (physical health, mobility challenges, and mental health) is imperative.
  4. That assuring a high standard of quality and sufficiency of services in various care settings and communities is essential.
  5. That careful attention is given to patients and families to assure that they have a realistic understanding of their discharge needs.
  6. That it is important to assure that an individual’s needs are reflected in discharge planning documents.
  7. That developing volunteer assistance networks to help in arranging and delivering services post-discharge is given prominence and direction.
  8. That assuring that comprehensive ongoing assessments of the quality and availability of community-based discharge planning resources remain a high priority.
  9. That discharge planning be required for hospital patients on observation status.
  10. That extending discharge planning services to minority communities is a collaborative effort between CMS and community partners.
  11. That expanding access to Ombudsman and Legal Assistance coordination on discharge planning remains an agency priority.


The Impact Act

The Center is pleased that CMS is embracing the IMPACT Act as a tool that requires the standardization of assessments from post-acute care settings (PACs) to facilitate care coordination to improve the health outcomes of Medicare beneficiaries.  This important and unifying step should promote better coordination among HHAs, SNFs, IRFs (Inpatient Rehabilitation Facilities), and LTCHs (Long-term Care Hospitals).  See §2 of the IMPACT Act, which added new §1899B to the Social Security Act (SSA) at https://www.; and see  We note that the IMPACT Act requires that assessment instruments be modified to utilize the standardized data required under new §1899B no later than October 1, 2018 for SNFs, IRFs, and LTCHs and no later than January 1, 2019 for HHAs. The seemingly long period for coordination and development of standardized assessments should be used to create smoother coordination and tighter, more targeted discharge plan development.

Design (Proposed §483.43(a))

Having input from the hospital medical staff, nursing leadership, and other pertinent services will ensure adequate input in the development of the discharge planning process. This input is critical.  Even so, a clearly defined “point person” is essential to making the design work happen.  This person should have sufficient authority and resources, including staff, to assure that the design process is completed within a specific and well-published timeframe. Moreover, the design process should have input from community-based discharge planners and from beneficiaries as voting members of design teams.

Applicability (Proposed §482.43(b))

We agree with the proposal to extend applicability of discharge planning services to certain observation patients such as persons who are undergoing same day surgeries and other outpatient same-day procedures where sedation or anesthesia is involved. However, we are concerned about other patients who are hospitalized on observation status for different reasons, who also need appropriate discharge plans for safety and effectiveness. We urge CMS to require discharge planning for all patients who stay overnight in a hospital but are classified as observation status “outpatients.” Without such a discharge planning requirement, these patients are in particular jeopardy of being poorly served after hospitalization.

Discharge Planning Process (Proposed §482.43(c))

We agree with the general breadth of the proposed discharge planning process, particularly the requirement that discharge planning should begin as early in the hospital stay as possible; that the anticipated post-discharge goals, preferences, and needs of the patients are considered; and that an appropriate plan is developed consistent with a patient’s needs and requests, including any co-morbidities.  We also find the reference to the holding in the Supreme Court’s decision, Olmstead v. L.C., 527 U.S. 581 (1999) to be most appropriate. Likewise, we appreciate CMS’ direction that hospitals must continue to abide by federal civil rights laws, including Title VI of the Civil Rights Act of 1964.

Proposed combining of §482.43(b)(2) and §482.43(c)(1) into a single requirement at §482.82(c)(1)

With respect to the proposal to combine and revise the existing requirements of §482.43(b)(2) and §482.43(c)(1) into a single requirement at §482.82(c)(1). We agree that having a registered nurse, a social worker, and other professionals involved are good points. What is missing is a requirement of physician involvement (beyond certification), particularly for persons in geriatric or related specialties, depending on patient need.

Proposed §482.82(c)(2) raises the important issue of a specific time period in which discharge planning should begin.  Having a more precise time for discharge planning to begin is a good idea.  Increasingly, however, individuals may not be in a hospital for two days and still require discharge planning. Thus, a 2–day requirement is often not appropriate.  Flexibility with timing is important to ensure all beneficiaries have a well-developed discharge plan.  In this regard, we appreciate CMS’ notion that the discharge planning process should be continuous and mindful of a patient’s changing circumstances.  Similarly, we support the notion put forth in proposed new §482.43(c)(9) that the patient’s discharge evaluation and the patent’s discharge plan are documented and completed timely.  Moreover, respect and consideration of the patient’s stated goals and preferences are essential. We are pleased that the essence of proposed §482.43(c)(9) is built upon the existing regulation. 

Discharge to Home (Proposed §482.43(d))

The proposal to re-designate and revise the current requirement at §482.43(c)(5) to become §482.43(d), discharge to home represents a useful expansion. It is a recognition of the importance of care in the home, or residence, or in one’s community (when there is no home).  It also acknowledges the importance of appropriate follow-up care by one’s primary care provider (PCP) or specialist.  Extending this requirement to HHAs, hospice services, or any other type of outpatient health care service is extremely important. Similarly, assuring that proper discharge planning includes instructions about follow-up care is essential.  Making sure that appropriate PAC services providers receive the patient’s discharge instructions at the time of discharge is critical. Assuring patient privacy in this process is likewise essential.  Similarly, we appreciate §482.43(d)(1) and its requirement that discharge instructions are to be provided to patients or to the patient’s caregiver/support person(s), or both. We also support the notion of a “teach back” requirement to confirm that a practitioner has explained to the patient what he or she needs to know in a manner that is understandable to the patient. See §482.43(d)(2) (proposed minimum requirements for discharge instructions).  Providing a medication list of the name, indication and dosage of each medication along with any significant risks and side effects of each medication is useful.  Requiring that the list be in the form of written instruction, on paper or electronic format, or both, is also helpful.  See §482.43(d)(2)(v).

New Post-Discharge Follow-Up Process (Proposed §482.43(d)(4))

This proposed rule is designed to reduce adverse events post-discharge, with a particular emphasis on medication compliance.  We agree with the notion that information about what to look for, in terms of signs of a possible adverse event, is helpful.  This type of assistance could possibly be extended to appropriate care at home and other appropriate settings and provide a measure of security for the patient and his or her caregivers in the home.

Transfer of Patients to another Health Care Facility (Proposed §482.43(e))

We agree that existing requirements with respect to the discharge and transferring of patients to other facilities should continue. The requirements to transfer medical information, discharge orders, etc., are essential to success in other care settings. Further, we agree that the failure to provide this necessary information has resulted in adverse consequences to many of the patients and families who contact the Center.  In addition to patient specific information, the information to be transferred should include a standardized set of contact information, starting with how to contact the Medicare Ombudsman as well as social services agencies, including legal assistance providers and sources to assist beneficiaries in accessing necessary medications, supports and services.  The list of patient support items included on page 68136, column 2, of the Federal Register announcement are essential and rightly apply to all care settings as addressed in this CMS proposed rule.

Requirements for Post-Acute Care Services (Proposed §482.43(f))

We support the re-designation of §482.43(c)(6) through (8) as new §482.43(f), with the addition of IRF and LTCH PAC providers, and extending the requirements consistent with the IMPACT Act.  We also agree that the requirement that Medicare-participating hospitals provide a list of available Medicare-participating HHAs and SNFs is useful.  Further, we are pleased that CMS proposes to provide information, if known, about providers that participate in a managed care organizations’ network, and that this information must be shared with patients, including documenting in the patient’s medical record that the information has been provided.  Similarly, the Center is pleased that the proposed rule extends to Home Health Agency discharge planning, reflecting an emphasis on coordination of services and the sharing of information.  This should lead to better cooperation and greater flexibility in meeting quality of care standards, including working collaboratively with entities that provide physical and occupational therapy.

Home Health Agency Discharge Planning Proposal (new 42 CFR §484.58)

The Center is pleased that CMS is proposing to update the HHA discharge requirement by adding proposed §484.58.  This rule would address the requirements of the IMPACT.  CMS is also soliciting comments on the timeline for HHA implementation of proposed discharge planning requirementsg:  addressing the needs of HHA patients, including the language barrier issues, mobility needs, and visual concerns, and physical, mental, and cognitive issues.  Further, the Center is pleased that this rule will require that the physician responsible for the home health plan of care of a patient be involved in the ongoing process of establishing the discharge plan, along with the patient’s goals of care and treatment preferences. And, where the beneficiary is to be transferred to another HHA, SNF, IRF, or LTCH, we agree that data on quality measures and data on resource use measures are to be made available to the patient.  See 484.58(a).

HHA Discharge or Transfer Summary Content (Proposed §484.58(b))

The Center agrees with the bulleted list of items to be included in the discharge summary (page 68138 of the proposal). These include the patient’s demographic information, including but not limited to name, sex, date of birth, race, ethnicity, and preferred language; contact information of the physician responsible for the home health plan of care; advance directive, if applicable; course of illness/treatment; procedures; diagnoses; laboratory tests and the results of pertinent laboratory and other diagnostic testing; consultation results; functional status assessment; psychosocial assessment; including cognitive status; social supports; behavioral health issues; reconciliation of all discharge medications (both prescribed and over the-counter); all known allergies, including medication allergies; immunizations; smoking status, vital signs; unique device identifier(s) for a patient’s implantable device(s), if any; recommendations, instructions, or precautions for ongoing care, as appropriate; patient’s goals and treatment preferences; the patient’s current plan of care, including goals, instructions, and the latest physician orders; and any other information necessary to ensure a safe and effective transition of care that supports the post-discharge goals for the patient.

Critical Access Hospital (CAH) Discharge Planning (Proposed §485.642(a))

The Center is pleased that CMS has outlined a design for CAH discharge planning.  See (Proposed §485.642(a)). As the proposal points out, there are currently no CAH discharge planning conditions of participation (CoP).

The proposal notes that the current CoPs at §485.631(c)(2)(ii) provides that a CAH must arrange for, or refer patients to, needed services that cannot be furnished at the CAH.  The Center agrees that there is benefit in improving the transfer and discharge requirements from an inpatient acute care facility, such as CAHs and hospitals.  Likewise, the Center agrees that mandates of the IMPACT Act raise important issues with respect to quality measures and the responsibilities of providers of care in all settings, including CAHs. For information on CAHs, see “Critical Access Hospital Population Health Summit Improving Population Health: A Guide for Critical Access Hospitals,” March 25-26, 2014, Bloomington, Minnesota, available at (site visited December 15, 2015). 

The Center is pleased to see that CMS is proposing that CAHs will be required to develop a discharge plan process and that CAHs develop discharge plans for each patient. We recommend, however, that CMS work toward a specific CoP for CAHs. Without this requirement, we fear that patients leaving a CAH may find it extremely difficult to obtain necessary discharge planning services where there is no specific CoP for discharge planning.  We are especially concerned that providing serves in rural areas that have fewer health care resources may result in Medicare beneficiary underservice.

Applicability (Proposed §485.642(b)

The Center is pleased that CAHs, under the CMS proposal, will be required to have a discharge planning process that is designed to identify the discharge planning needs of each patient and to develop an appropriate discharge plan; that physicians must be involved and certify that the individual is about to be discharged or transferred to a hospital within 96 hours after admission to the CAH.. We find, however, that a 96 hour wait before discharge planning commences is far too long; that discharge planning should begin at the beginning of hospitalization, whether the patient is in a CAH or in any other hospital setting.  On the other hand, we agree that the hospital discharge planning process should apply to all patients identified by staff or to those who request discharge planning evaluations and services.  This would make the CAH rule consistent with the existing CoP applicable to Medicare participating hospitals under §482.43.

Discharge Planning Process (Proposed §485.642(c))

We agree with the scope of services to be included in the proposed discharge planning process for CAHs, including identifying the anticipated post-discharge goals, preferences, and discharge planning needs of the patients.  We also agree that a registered nurse, social worker, or other personnel qualified in accordance with the CAH’s discharge planning policies must coordinate the discharge needs evaluation and development of the discharge plan.  With respect to when the planning process should begin, we recommend that the process begin at admission as opposed to a 24 hour delay. 

The Center agrees with the requirement that CAHs consider caretaker support availably and community based care services as well as the capability of caregivers to provide proper assistance in a safe manner.  See proposed §485.642(c)(3).  The Center also agrees with the proposed §§485.642(c)(6) through 485.642(c)(9) with respect to patient and caregiver involvement, patient’s goals of care and treatment preferences.  We also agree with the requirement that CAHs must assist patients, their families, or their caregivers, in selecting PAC providers by using and sharing data that includes but is not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures.  Likewise, the Center appreciates that the above proposals fit well within the scope and direction of the IMPACT Act.

Discharge to Home (Proposed §485.642(d)(1) through (3))

The Center is pleased with the establishment of a new “discharge to home” standard.  This requirement focuses on caregiver support, including caregiver instruction, medication management, and patient understanding of written discharge instructions.  These important additions should enhance patient well-being and provide concrete steps to evaluate the success of discharge planning efforts.

Transfer of Patients to another Health Care Facility (Proposed §485.642(e))

We support adding the proposed rule governing the transfer of patients to another health care facility.  We agree with the proposed list of demographic information to be collected, in addition to date of birth, race, ethnicity and preferred language.

We are pleased that the CMS proposal calls for the following data: an advance directive, if applicable; the course of the illness or treatment; procedures; diagnoses; laboratory tests and the results of pertinent laboratory and other diagnostic testing; consultation results; functional status assessment; psychosocial assessment, including cognitive status; social supports; behavioral health issues; reconciliation of all discharge medications with the patient’s pre-hospital admission or registration; medication (both prescribed and over-the-counter); all known allergies, including medication allergies; immunizations; smoking status; vital signs; unique device identifier(s) for patient’s implantable device(s), if any; all special instructions or precautions for ongoing care; as appropriate patient’s goals and treatment preferences; and any other necessary information including a copy of the patient’s discharge instructions; the discharge summary; and any other documentation as applicable, to ensure a safe and effective transition of care that supports the post-discharge goals for the patient.

The Center for Medicare Advocacy appreciates the opportunity to offer these comments on this important expansion of discharge planning rights.


Respectfully submitted, 

Alfred J. Chiplin, Jr.
Senior Policy Attorney
Center for Medicare Advocacy

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