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On May 17, 2013, the Centers for Medicare & Medicaid Services (CMS) released an update of Appendix A of the State Operations Manual (SOM) revising its interpretive guidelines for hospital Discharge Planning.[1]  Medicare discharge planning is a Condition of Participation for hospitals, including psychiatric hospitals.[2] Medicare-participating hospitals must make their discharge planning process available to all patients upon request, even those who are not Medicare patients.[3]

CMS' new guidance to surveyors provides additional detail about the role and functions of hospitals in the transition of patients from the hospital setting to other care settings, including the home.  Unfortunately, the new guidance is provided only in the context of hospitals that are not identified as psychiatric hospitals.  Guidance for the psychiatric hospital setting is set forth elsewhere and is not extensive.[4] The Center for Medicare Advocacy (the Center) has long advocated that Medicare's discharge planning requirements for all hospital settings should to be more comprehensive.  Effective discharge planning is a key element of successful post-hospital care.[5] 

Some Highlights from the Update

Over the course of the next several months, the Center will provide an expansive discussion of the new survey and certification guidance.  For now, we wish to alert you to this new material and emphasize its importance to client advocacy.

CMS' update acknowledges new terminology such as "transition planning" or "community care transitions" and the interrelatedness of such terms to care coordination and discharge planning.  In the guidance, however, CMS continues to use the language of the Medicare statue and regulations which is "discharge planning."  We are pleased that CMS notes in its interpretive guidelines that "a poor discharge planning process may slow or complicate the patient's recovery, may lead to readmission to a hospital, or may even result in the patient's death."[6]  In this regard CMS is appropriately placing a major emphasis on the role and responsibility of participating hospitals to "employ a discharge planning process that improves the quality of care for patients and reduces the chances of readmissions."[7]

CMS states in its new guidance that hospitals might consider, on a voluntary basis, using an abbreviated discharge planning process for certain categories of outpatients such as patients in so-called outpatient observation status, persons who have received same day surgery, and certain categories of emergency department discharges.  CMS acknowledges that often people receiving outpatient services, including those classified as outpatients who stay in the hospital on observation status, even those who are in the hospital for 48 hours or less, may have complex medical needs for which discharge planning services are important.[8] 

With respect to evaluating who will need discharge planning services, CMS identifies several factors: (a) the patient's functional status and cognitive ability; (b) the type of post-hospital care the patient requires, (c) whether such care requires the services of health care professionals or facilities, (d) the availability of the required post-hospital health care services to the patient; and (e) the availability and capability of family and/or friends to provide follow-up care in the home.[9]

The new guidance places an increased emphasis on hospitals knowing the capabilities and capacities of the facilities to which they refer patients for post-hospital care.  The guidance notes that this information should inform decisions about placement and should play a role in reducing re-hospitalizations.[10] This is critically important.  When facilities receive patients whose care-needs are beyond their capabilities, those patients generally get sent to an emergency department or readmitted to an acute care facility.[11] 

The new guidance also notes the importance of the hospital discharge planning process, including a general awareness of the patient's financial capacities, given the costly nature of post-hospital care in many instances.  This awareness is particularly important for those patients who may be eligible for Medicaid-covered services.[12]

Also noted in the new guidance is the importance of engaging the patient and family, or patient representative in the discharge planning process.  CMS acknowledges that such engagement can provide valuable information that can enhance the likelihood of the success of discharge planning.[13] In addition, the new guidance places an emphasis on a team approach to discharge planning.  The team approach can support care coordination and collaboration among team members and can enhance the timely completion of the discharge planning process.[14]

With respect to persons performing discharge planning evaluations and developing discharge plans, the new guidance expands on the qualification of discharge planners.  In particular, the guidance says that the discharge planning evaluation must be developed by a registered nurse, social worker, or other appropriate qualified personnel, or by a person who is supervised by such personnel, including prior discharge planning experience.  Moreover, the guidance makes it clear that hospitals' written policies and procedures must specify the qualifications for personnel other than registered nurses or social workers who develop or supervise the development of the discharge plan.[15]

The new interpretive guidelines add valuable information about the initial implementation of the discharge plan.  The guidance requires surveyors to ascertain what level of patient and family education has been provided; whether there are written discharge instructions are legible and are in plain language, culturally sensitive and age appropriate; and whether supplies (such as materials for changing dressings on wounds that might need attention immediately post-hospital discharge) have been provided. Additionally, Surveyors are also required to ascertain whether a patient has a list of all medications that should be taken post-discharge, with clear indication of changes from the patient's pre-admission medications.[16]


The new guidance for surveyors represents a good step toward making the discharge planning process a more useful tool. However, discharge planning should be required for observation status patients, and advocates should continue to press CMS for more comprehensive discharge planning rules, particularly for the psychiatric hospital setting.


[1] Medicare’s hospital discharge planning statutory requirements are located at 42 USC §1395x(ee); Medicare hospital discharge planning regulations are located at 42 CFR §482.43.  CMS’ new survey and certification guidance, Ref: S&C: 13-32- Hospital, is available at The guidance is effective immediately and is to be communicated to all state and regional [survey] training officers within 30 days of May 17, 2013, the date on which the guidance was issued. Id.  Hospital discharge planning interpretive guidelines, including discharge planning (482.43) are located at
[2] See footnote 1, above.
[3] See 42 CFR 482.43, and the discussion of the Secretary in introducing the discharge planning regulations at 59 Fed. Reg. 64141, at 64143 (Dec. 13, 1994). 
[4] Discharge planning regulations for psychiatric hospitals are at 42 CFR §482.61(e); survey and certification guidance for psychiatric hospitals is located at  But see also CMS’s Medlearn pamphlet at
[5] See the Center’s corpus of discharge planning material and writing at:
[6] See S&C: 13-32- Hospital, Tag A-0799, §482.43.
[7] Id.
[8] Id.
[9] Id., Tag A-0800, §482.43(a).
[10] Id., Tag A-0806, §482.43(b)(3).
[11] Id.
[12] Id.
[13] Id. See also Tag A-0811, §482.43(b)(6).
[14] Id. Tag A-0810, §482.43(b)(5).
[15] Id. Tag A-0807, §482.43(b)(2), Tag A-0818, §482.43(c).
[16] Id. Tag A-0820, §482.43(c)(3).

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