Practice Economics

Medicare Rule Change Raises Stakes for Hospital Discharge Planning


Raised Expectations

When she presents information to hospitalists about the little-known revision to Medicare’s condition of participation for discharge planning by hospitals, most hospitalists have no idea what Amy Boutwell, MD, MPP, is talking about. Even hospitalists who are active in their institutions’ efforts to improve transitions of care out of the hospital setting are unaware of the change, which was published in the Centers for Medicare & Medicaid Services’ Transmittal 87 and became effective July 19, 2013.

“I just don’t hear hospital professionals talking about it,” says Dr. Boutwell, a hospitalist at Newton-Wellesley Hospital and president of Collaborative Healthcare Strategies in Lexington, Mass. “When I say, ‘There are new rules of the road for discharge planning and evaluation,’ many are not aware of it.”

The revised condition states that the hospital must have a discharge planning process that applies to all patients—not just Medicare beneficiaries. Not every patient needs to have a written discharge plan—although this is recommended—but all patients should be screened and, if indicated, evaluated at an early stage of their hospitalization for risk of adverse post-discharge outcomes. Observation patients are not included in this requirement.

The discharge plan is different from a discharge summary document, which must be completed by the inpatient attending physician, not the hospital, and is not directly addressed in the regulation. The regulation does address the need for transfer of essential information to the next provider of care and says the hospital should have a written policy and procedure in place for discharge planning. The policy and procedure should be developed with input from medical staff and approved by the hospital’s governing body.

Any hospitalist participating with a hospital QI team involved in Project BOOST is helping their hospital comply with this condition of participation.

—Mark Williams, MD, FACP, SFHM, principal investigator of SHM’s Project BOOST

Transmittal 87 represents the first major update of the discharge planning regulation (Standard 482.43) and accompanying interpretive guidelines in more than a decade, Dr. Boutwell says. It consolidates and reorganizes 24 “tags” of regulatory language down to 13 and contains blue advisory boxes recommending best practices in discharge planning, drawn from the suggestions of a technical expert panel convened by CMS.

That panel included many of the country’s recognized thought leaders on improving care transitions, such as Mark Williams, MD, FACP, SFHM, principal investigator of SHM’s Project BOOST; Eric Coleman, MD, MPH, head of the University of Colorado’s division of health care policy and research and creator of the widely-adopted Care Transitions Program (, and Dr. Boutwell, co-founder of the STAAR initiative (

The new condition raises baseline expectations for discharge planning and elevates care transitions efforts from a quality improvement issue to the realm of regulatory compliance, Dr. Boutwell says.

“This goes way beyond case review,” she adds. “It represents an evolution from discharge planning case by case to a system for improving transitions of care [for the hospital]. I’m impressed.”

The recommendations are consistent with best practices promoted by Project BOOST, STAAR, Project RED [Re-Engineered Discharge], and other national quality initiatives for improving care transitions.

“Any hospitalist participating with a hospital QI team involved in Project BOOST is helping their hospital comply with this condition of participation,” Dr. Williams says.

In the Byzantine structure of federal regulations, Medicare’s conditions of participation are the regulations providers must meet in order to participate in the Medicare program and bill for their services. Condition-level citations, if not resolved, can cause hospitals to be decertified from Medicare. The accompanying interpretive guidelines, with survey protocols, are the playbook to help state auditors and providers know how to interpret and apply the language of the regulations. The suggestions and examples of best practices contained in the new condition are not required of hospitals but, if followed, could increase their likelihood of achieving better patient outcomes and staying in compliance with the regulations on surveys.

“If hospitals were to actually implement all of the CMS advisory practice recommendations contained in this 35-page document, they’d be in really good shape for effectively managing transitions of care,” says Teresa L. Hamblin, RN, MS, a CMS consultant with Joint Commission Resources. “The government has provided robust practice recommendations that are a model for what hospitals can do. I’d advise doing your best to implement these recommendations. Check your current processes using this detailed document for reference.”

Discharge planning starts at admission, Hamblin says. If the hospitalist assumes that responsibility, it becomes easier to leave a paper trail in the patient’s chart. Other important lessons for hospitalists include participation in a multidisciplinary approach to discharge planning (i.e., interdisciplinary rounding) and development of policies and procedures in this area.

“If the hospital has not elected to do a discharge plan on every patient, request this for your own patients and recommend it as a policy,” Hamblin says. “Go the extra mile, making follow-up appointments for your patients, filling prescriptions in house, and calling the patient 24 to 72 hours after discharge.”

Weekend coverage, when case managers typically are not present, is a particular challenge in care transitions.

“Encourage your hospital to provide reliable weekend coverage for discharge planning. Involve the nurses,” Hamblin says. “Anything the hospitalist can do to help the hospital close this gap is important.”

Larry Beresford is a freelance writer in Alameda, Calif.

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