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Discharge Planning Beyond the Day of Discharge

By August 27, 2019C&A Blog

The Affordable Care Act (ACA) established the Hospital Readmission Reduction Program (HRRP) in 2012.  The HRRP is a Medicare value-based purchasing program that reduces payments to hospitals with risk adjusted readmission rates beyond expectations.  The overall rate of unplanned readmission after discharge from the hospital (also called “hospital-wide readmission”) focuses on whether patients who were discharged from a hospital stay were hospitalized again within 30 days. The idea was that the overall rate of unplanned readmission would show whether a hospital is doing its best to prevent complications, provide clear discharge instructions to patients, and help ensure patients make a smooth transition to their home or next level of care.

Research has shown that approximately 19.6% of Medicare beneficiaries were rehospitalized within 30 days of discharge and 34.0% within 60 days of discharge. 70.5% of those surgical patients were subsequently readmitted within 30 days for a medical cause. Only 10% of rehospitalizations were estimated to have been planned.

Reducing the number of preventable hospital readmissions is a major initiative for Patient Safety professionals.  CMS and other accrediting agencies have been holding hospitals accountable for complying with discharge planning requirements for years.  However, one new element is being focused on today – that is the organizations overall strategy for reducing readmissions.

What does Discharge Planning have to do with Readmissions?

When the discharge planning process is well executed, and absent unavoidable complications or unrelated illness or injury, the patient continues to progress towards the goals of his or her individualized plan of care after discharge.  Some readmissions may not be avoidable while some may be.  It is the focus of surveyors to identify if hospitals are identifying and controlling the factors they can for the discharged patient.

Research has shown 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.  In order to reduce readmissions, organizations must develop strategies to address the multiple factors that may contribute to the increased levels of readmissions. These factors may include:

  • Poor quality care,
  • Poor transitions between different care settings,
  • Patients discharged prematurely,
  • Discharged to inappropriate settings,
  • Patient’s not receiving adequate information or resources to ensure a continued progression of services,
  • Poorly coordinated care,
  • Incomplete communication or
  • Poor information exchange between inpatient and community‐based providers.

While hospitals are not solely responsible for the success of their patients’ post-hospital care transitions, they are financially impacted.  Under the discharge planning CoP, hospitals are expected to employ a discharge planning process that improves the quality of care for patients and reduce the chances of readmission.

Surveyors are reviewing the Discharge Planning process from multiple fronts.  First, surveyors will review medical records to determine if the patient received or is receiving appropriate individualized discharge planning activities and instructions.  Next, surveyors review readmission rates to see if the data is above expected rates. Surveyors will interview staff to understand the discharge planning process and staff understanding of the process.  Lastly, surveyors may interview active or discharged patients to see how prepared the patient felt prior to discharge.  If any of these reviews present concerns, surveyors will continue to review policies and procedures related to the discharge planning process.

Organizations are ‘at risk’ in multiple areas related to the discharge planning process, including:

  • Staff’s ability to speak to the discharge planning process
  • Staff’s ability to speak to discharge education processes
  • Documentation of discharge planning starting at the earliest possible time of admission
  • Documentation of discharge planning activities and education in the medical record
  • Documentation of discharge planning activities and education in a language and manner the patient prefers
  • Assessment and re-assessment of discharge planning activities based on patient’s condition throughout their stay
  • Follow-up or Transitions of Care Reviews for discharged patients

Organizational Strategy

Hospital discharge planning is a process that involves determining the appropriate post-hospital discharge destination for a patient; identifying what the patient requires for a smooth and safe transition from the hospital to his or her discharge destination; and beginning the process of meeting the patient’s identified post-discharge needs. This approach recognizes the shared responsibility of health care professionals and facilities, as well as patients and their support persons, throughout the continuum of care, and the need to foster better communication among the various groups.

Discharge planning should be a staged process:

  • Screening all inpatients to identify and determine which ones are at risk of adverse health consequences post-discharge;
  • Evaluation of the post-discharge needs of inpatients identified in the first step;
  • Development of an initial discharge plan indicated by the evaluation;
  • Reassessment of the patients’ needs and condition throughout their stay to update the discharge plan;
  • Initiation of the implementation of the discharge plan prior to the discharge of an inpatient;
  • Education of discharge plan in a language and manner the patient prefers;
  • Follow-up post discharge to determine if patient has needs developing that may result in a readmission (also known as Transition of Care reviews).


The HRRP itself does not provide resources to hospitals to fund readmission reduction interventions and care redesign. However, CMS has provided additional funding for transitional care efforts through complementary programs, such as the Community-based Care Transitions Program (CCTP), which is aimed to test models for improving care transitions and reducing readmissions and Transitional Care Management Services – provided two new current procedural terminology (CPT) codes). These transitional care efforts and CPT codes are geared at assisting hospitals provide a discharge planning process that spans the continuum of care with the goal of reducing readmissions or negative patient outcomes.


CMS State operations Manual, 10-12-2018, §482.43 Condition of Participation: Discharge Planning

The hospital must have in effect a discharge planning process that applies to all patients. The hospital’s policies and procedures must be specified in writing.

Joint Commission Comprehensive Accreditation Manual for Hospitals, 2019

PC.01.01.01 (EP 1) Does the organization accept the patient for care, treatment, and services based on its ability to meet the patient’s needs? Are administrative and clinical decisions coordinated for patients under legal or correctional restrictions on the following:

  • The use of seclusion and restraint for nonclinical purposes?
  • The imposition of disciplinary restrictions?
  • The restriction of rights?
  • The plan for discharge and continuing care, treatment, and services?
  • The length of stay?

PC.04.01.01 (EP 1, 22,23,24,25,26) Does the hospital follows a process that addresses the patient’s need for continuing care, treatment, and services after discharge or transfer?

PC.04.01.03 (EP 1,2,3,4,5,6,10,11) Does the organization discharge or transfer the patient based on his or her assessed needs and the organization’s ability to meet those needs?

PC.04.01.05 (EP 1,2, 7) Before the organization discharges or transfers a patient, does it inform and educate the patient about his or her follow-up care, treatment, and services?

James Ballard

Author James Ballard

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