On June 6, 2023, the Center for Medicare and Medicaid Services (CMS) provided a Quality Safety & Oversight (QSO) memorandum outlining CMS-identified concerns with respect to the patient discharge process (Memo). As set forth within 42 CFR 482.43, hospitals must have "an effective discharge planning process that focuses on the patient's goals and treatment preferences and includes the patient and his or her caregivers/support person(s) as active partners in the discharge planning for post-discharge care." Within the Memo, CMS emphasizes the importance of ensuring that post-acute care (PAC) providers, including skilled nursing facilities and home health agencies, are provided with accurate and complete information relating to a patient's condition and treatment in order to protect and improve a patient's health and safety. According to CMS, the consequences of inaccurate and incomplete information lead to "avoidable readmissions, complications, and other adverse events." The Memo aims to remind both discharging hospitals and PAC providers to shore up their discharge procedures to ensure that both the PAC providers and the discharged patients are properly supported.
With respect to ensuring accurate and complete patient information, CMS has identified the following areas of concern:
- Information relating to patients with serious mental illness, complex behavioral needs, and/or substance use disorder.
- Comprehensive listings of all medications prescribed to a patient during, and prior to, their hospital stay.
- Information about skin conditions noted by the hospital.
- Usage of durable medical equipment.
- Patient preferences, goals for care, and information relating to a patient's home environment.
CMS further notes that such information is crucial to ensuring that PAC providers can continue to provide the appropriate level of care upon discharge. It is important to understand that some PAC providers may not be properly equipped nor trained to care for certain conditions and, further, may place a patient in harm's way by accepting the transfer and admission of a patient that a PAC provider cannot appropriately accommodate.
CMS acknowledges within its Memo that the discharge process can be complex, but emphasizes that the appropriate policies and procedures be put into place to ensure that both PAC providers and patients continue to receive the appropriate level of care upon discharge. CMS goes on to provide the following recommendations to assist in improving the discharge process:
Of course, these CMS recommendations are not comprehensive as both hospitals and PAC providers can do more to improve not only the discharge process but the general efficiency and function of each of their respective operations. Research and studies support that more proactive planning for discharge and improved communication through the utilization of EHRs can significantly reduce delays and ensure patients avoid unnecessary harm upon discharge, as noted by CMS in its Memo. Both hospitals and PAC providers can always improve communication and make the commitment to constantly analysis their discharge policies and procedures to make real-time improvements to protect patients throughout the entire care process.
