Discharge planning is an important tool for reviewing and making arrangements for on-going healthcare needs across healthcare settings, including hospitals, skilled nursing facilities, home health, or hospice. When focusing on discharge planning, beneficiaries and their advocates should carefully read all documents that purport to explain rights to services, including discharge evaluations and discharge planning documents. They should also question treating physicians, nurses, social workers, home health and hospice care providers about necessary services as the beneficiary’s condition improves or declines, and voice opinions and concerns about care; and participate fully in all care decisions. They should also be aware of appeal rights should problems arise.
The Centers for Medicare & Medicaid Services (CMS) is in the final stages of developing a checklist called “Planning for Your Discharge.” Focus groups have been meeting throughout the year to review and refine the document. When completed, the checklist will be offered as a tool to be used by beneficiaries and their families to work with their providers in preparation for a discharge from a health care setting. The checklist will be an important starting point for beneficiaries and their advocates in focusing on the specifics of discharge planning.
Discharge Planning Checklist
The checklist re-emphasizes the importance of talking to healthcare providers about where one is to go following care in a particular healthcare setting, as well as the need to consider how, and by whom, care will be provided after such transitions.
The discharge planning checklist raises the following questions and concerns for beneficiaries to consider:
- where care will be provided and who will help after discharge;
- whether the beneficiary understands his or her health condition, what problems to watch out for, and how to handle them;
- the beneficiary ‘s level of knowledge about the drugs that have been prescribed for what conditions, including how and when to take them;
- whether the beneficiary has ascertained what medical equipment (like a walker) will be needed;
- whether – and for how long – the beneficiary will need help with bathing, dressing, grooming, using the bathroom, shopping for food, making meals, doing housework, paying bills, getting to doctors’ appointments, picking up prescription drugs;
- the beneficiary ‘s comfort level with performing care tasks such as using medical equipment, changing a bandage, or giving a shot;
- whether family members or other caregivers understand the help the beneficiary will need from them;
- concerns about how well family members are coping with the beneficiary’s illness;
- whether the beneficiary knows which doctor or other healthcare provider to call if there are questions or problems;
- does the beneficiary understand what appointments and tests will be needed in the next several weeks after discharge;
- whether the beneficiary has been provided with understandable written discharge instructions, including instructions for medications and a current health status summary;
- whether the beneficiary understands the need for home health, nursing, or hospice services and how to go about obtaining them;
- one’s level of knowledge about available community resources; and
- the beneficiary’s level of understanding of what insurance will cover for prescription drugs, equipment, and services that will be needed, and what the beneficiary will have to pay.
The CMS checklist also states that if the Medicare beneficiary feels that he or she is being asked to leave a hospital or other health care setting too soon, the beneficiary may have appeal rights and should contact the Quality Improvement Organization (QIO) for an explanation of those rights. Beneficiaries should always be aware of the importance of appeal rights in assuring that proper attention has been given to their care needs as they move through various care settings. Planning issues are often linked to the question of whether a discharge is occurring too soon, or is otherwise inappropriate. In many instances, such needs and concerns are not properly addressed without resorting to an appeal.
Medicare Discharge Planning Requirements
A. Hospital Requirements
While currently under-utilized, discharge planning is well-defined by the Medicare statute and regulations. Moreover, CMS requires that hospitals, as a condition of Medicare participation, provide discharge planning services upon request to any patient, including non-Medicare patients.
A Medicare-participating hospital must:
- identify, at an early stage of hospitalization, patients who are likely to suffer adverse health consequences upon discharge in the absence of discharge planning services;
- conduct, on a timely basis, a discharge planning evaluation for all patients identified by their physicians as needing discharge planning services, as well as any patient requesting a discharge planning evaluation;
- discuss the evaluation with the patient (and the patient’s representatives);
- place the discharge planning evaluation in the patient’s medical record; and
- review the elements of the discharge plan evaluation. 
Discharge planning discussions should begin on admission. Beneficiaries and their representatives should look for, and carefully review, the “Important Message from Medicare” (IM) which is given to beneficiaries upon admission to a Medicare-participating hospital. The IM is a general notice that explains a variety of rights, including the right to discharge planning services. The “Medicare Discharge Rights” segment of the IM is on the front of the notice and comprises a significant portion of that initial page.
When a hospital issues a notice of a proposed discharge, it will give the beneficiary a second copy (follow-up) of the “Important Message from Medicare,” which contains information about how to appeal the proposed discharge. If the beneficiary thinks the proposed discharge is inappropriate, the beneficiary or his or her advocate should make that known to the hospital. Once this is done, the hospital is required to issue the beneficiary a “Detailed Notice of Discharge. This notice includes language that explains that it is a hospital-initiated notice and not an official Medicare decision and that the beneficiary has the right to have the appropriateness of the discharge reviewed by the Quality Improvement Organization for a formal Medicare decision.
B. Skilled Nursing Facility (SNF) Requirements
Medicare regulations require SNFs to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet all of a resident’s medical, nursing, mental and psycho-social needs that are identified in the comprehensive assessment. Facilities are to assess the resident’s “discharge potential” – an assessment of the facility’s expectation of discharging the resident from the facility within the next three months. A facility must provide sufficient preparation and orientation to residents to ensure that their transfer or discharge from the facility is safe and orderly.
Residents’ records should contain a final resident discharge summary which addresses a resident’s post-discharge needs. This should include a post-discharge plan of care, developed with the participation of the resident and his or her family, in order to assist the resident to adjust to his or her new living environment.  It is important to note that this requirement applies to discharges to a private residence, to another nursing facility, or to another type of residential facility, such as board and care or nursing facilities.  A “post-discharge plan of care” includes assessing continuing care needs and developing a plan designed to ensure that the individual’s needs will be met after discharge from the facility into the community.
The Medicare statute provides special appeal rights for beneficiaries who are at risk of discharge or termination of services from a SNF. The regulations require that, for any termination of service, the provider of the service must deliver valid written notice to the beneficiary of the provider’s decision to terminate services.
C. Home Healthcare Setting Requirements
Discharge planning rights in the home healthcare context are not as well developed as in other care settings. The appropriate focus is thus on advocacy to keep services in place. Adequate notice of terminations and denials of care are central to keeping services in place. The Medicare statute provides for an expedited appeal to the QIO for beneficiaries who are at risk of discharge or termination of services from a home healthcare agency (HHA).
Home healthcare agencies are also required to give written or oral notice concerning when Medicare will pay for services and when there is a change. For this purpose, agencies use the home health advanced beneficiary notice (HHABN). Notice via an HHABN includes the right to an expedited appeal when an HHA plans to terminate services or to discharge the beneficiary.
The Medicare program requires each participating HHA to provide its Medicare home health patients with:
- information, in advance, about the care and treatment to be provided by the agency;
- full information, in advance, of any changes in the care or treatment to be provided by the agency that may affect the individual’s well-being;
- the right to participate in the planning of care and treatment or changes in care or treatment;
- the right to be fully informed orally and in writing (in advance of coming under the care of the agency) of any changes in the charges for items or services to be provided, as well as to be fully informed of the beneficiary’s rights and entitlements under Medicare.
D. Hospice Requirements
Medicare-participating hospice programs must have in place a discharge planning process that takes into account the prospect that a patient’s condition might stabilize or otherwise change such that the patient cannot continue to be certified as terminally ill. The discharge planning process must include planning for any necessary family counseling, patient education, or other services before the patient is discharged because he or she is no longer terminally ill.
For any termination of hospice service, Medicare hospice regulations require that the provider of the service deliver valid written notice to the beneficiary of the provider’s decision to terminate services. This notice must be delivered no later than the next-to-last time services are furnished. This notice triggers the Medicare beneficiary’s right to request an expedited determination from the QIO, which must then render a decision within 72 hours of the request.
A hospice program may discharge patients under only three circumstances:
- the patient moves out of the hospice’s service area or transfers to another hospice;
- the hospice determines that the patient is no longer terminally ill; or
- the hospice determines, under a policy set by the hospice for the purpose of addressing discharge for cause, that the behavior of the patient (or other persons in the patient’s home) is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired.
There are no specific appeal rights when a hospice beneficiary is discharged for cause. However, the beneficiary must be notified by the hospice when discharge for cause is being considered. The provider must make a serious effort, including documentation of that effort, to resolve the problems at issue, and must ascertain that the proposed discharge is not related to a substantive dispute about the appropriate use of necessary hospice services.
The discharge planning check list heightens CMS’s emphasis on the importance of discharge planning. In conjunction with the discharge planning rights outlined above, it gives beneficiaries and their advocates more tools to use in assuring that beneficiaries receive the healthcare services they need as they move from care setting to care setting.