Follow ACMA
Twitter Facebook Linkedin
Updates & Calls to ActionMake a Donation

CMS Announces Final Discharge Planning Rule: Compliance due by Nov. 29

Posted on: 11/16/2019

On September 30, 2019, the Centers for Medicare and Medicaid Services (CMS) published a final rule to implement new discharge planning requirements for hospitals, critical access hospitals and post-acute care (PAC) services entities. Originally mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), the long-awaited action from CMS comes four years after the original proposal was published.

“Discharge planning is an important component of a successful transition from hospitals and PAC settings.” – CMS

Read the final discharge planning rule >>>

ACMA’s Overview and Quick Reference

ACMA has been following the rule’s development since it was first proposed back in November 2015. The final rule has been scaled back from the initial proposal to lessen the regulatory burden on covered entities and to facilitate a smooth transition to compliance. CMS also recognizes and values the efforts with Patients over Paperwork and has chosen not to “focus on prescriptive and burdensome process details, and more on patient outcomes and treatment preferences through the enhanced information exchange and innovative practice standards”. Ultimately, CMS has concluded that most covered entities have already implemented the rule in some form or fashion, and because of that, the agency is mandating compliance by November 29, 2019 (60 days after publication).

“The location to which a patient may be discharged should be based on the patient's clinical care requirements, available support network, and patient and caregiver treatment preferences and goals of care.”- CMS

5 Things to Know About the Rule:

1. A hospital’s discharge planning process must identify at-risk patients and hospitals must provide a timely discharge planning evaluation of patients, and update the evaluation and plan as needed. (The discharge planning evaluation must be documented in the patient’s medical record.)

2. A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to, skilled nursing (SNF), home health services (HHA), inpatient rehabilitation facility (IRF), long term acute care hospitals (LTCH), and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services. CMS also recognizes situations may rise where patients prefer not to participate or refuse, and states this the declination or refusal is to be documented in the medical record as well.

3. Hospitals must assist patients, their families, or the patient’s representative in selecting a post-acute care provider by using and sharing patient-relevant data on quality measures and resource use measures of area services, including HHA, SNF, IRF, or LTCH data, and by providing a list of HHAs, SNFs, IRFs, or LTCHs that are available to the patient, that are participating in the Medicare program, and that serve the geographic area of the hospital or the geographic area requested by the patient. The hospital must also document in the patient’s medical record that the list was presented to the patient or to the patient’s representative. CMS expects hospitals to make best efforts in providing this information to align patient’s treatment goals and preferences. CMS also expects providers to preserve the expectation of freedom of choice for patients and their caregivers in selecting post acute services and providers where required.

4. Hospitals must discharge patients with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences to the appropriate post-acute care service providers or other practitioners responsible for the patient’s follow-up or ancillary care. This is not a new requirement, and patient discharge instructions are already required as a part of the medical record under Medical Record Services requirements in S482.24.

5. Hospitals must share with patients their medical records in a timely manner upon request and in a form or format that is easily accessible and readable.

What is CMS Saying?

“[This] rule puts patients in the driver’s seat of their care transitions and improves quality by requiring hospitals to provide patients access to information about PAC provider choices, including performance on important quality measures and resource-use measures – including measures related to the number of pressure ulcers in a given facility, the proportion of falls that lead to injury, and the number of readmissions back to the hospital.”

Read the CMS press release here: Statement on Discharge Planning Rule >>>

Return to Legislative Postings


ACMA COVID-19 Resource Center

ACMA is committed to keeping you informed about our actions in response to the COVID-19 pandemic. Stay up to date via the ACMA COVID-19 Resource Center where you will find helpful information, members-only resources and guidance for case management and transitions of care specific to this evolving situation. We encourage you to visit the resource center and to lean on ACMA as your trusted source during this time of uncertainty. Thank you for your work in your communities and for all you are doing to address this pandemic. Access ACMA COVID-19 Resource Center >>>

Watch Sessions & Earn Continuing Education Credits

Get your CEs by participating in the 2020 ACMA Virtual National Conference to meet your license or ACM, CMAC and CCM renewal needs. Up to 28.8 contact hours are available for RNs and SWs. ACM, CMAC and CCMs earn up to 24.0 recertification credits. AMA PRA Category 1 Credits also available. Preview Sessions >>> | Register Here >>>

Are You Ready for National Case Management Week?

National Case Management Week 2020 (NCMW2020) is October 11-17! Join us as we recognize and show appreciation for case management and transitions of care professionals across the country. This year's ACMA theme is Transitions Through Care, Expertise and Integrity. ACMA hopes you will celebrate NCMW 2020 and recognize the dedication, compassion and patient care outcomes achieved by case managers in your organization. Across all care settings, case managers are making the difference! Celebrate NCMW! >>> | Gear Up! >>>

FREE! Collaborative Case Management: Special COVID-19 Issue

ACMA has launched a new special issue of "Collaborative Case Management," a peer-reviewed journal exclusively for members. Inside, industry partners from across the country share their insights into battling the COVID-19 pandemic. Experts provide you with tools, resources, ideas and experiences covering all aspects of the continuum of care. Not a member of ACMA? We've still got you covered. This special issue is free to download to provide you a sampling of all that ACMA membership has to offer. Read it Today! >>>

Compass Mid-Year Course Release

Compass has just released a new course, Case Management Emergency Preparedness, which was developed to support and train case management staff and leadership on essential aspects of emergency preparedness, including lessons-learned with COVID-19 case studies. Current compass users can simply log-in to your dashboard to access the new course. If you're not a Compass subscriber, learn more about the product.>>>

Fall ACM Certification Review Webinar

Register now for the ACM Certification Review Workshop, taking place on October 17 and October 24. All resources are developed by seasoned case managers and designed exclusively for ACM Certification exam prep. Learn more and register. >>>

Validate Your Expertise Through Professional Certification

The Accredited Case Manager (ACM) Certification is for health care delivery system case management professionals and tests core case management knowledge that is shared by nurse and social work case managers. Case Management Administrator Certification (CMAC) validates the competency of case management administrators, managers and aspiring leaders and promotes professional practice standards. If you are not yet certified, we encourage you to apply and enhance your professional practice by putting a credential after your name. The application deadline is November 15 in order to test in January-March 2021. ACM >>> CMAC >>>

American Case Management Association
40 Rahling Circle
Little Rock, Arkansas 72223
Phone: 501-907-ACMA (2262)
Fax: 501-227-4247