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Implications of CMS’ Discharge Planning Requirements

Ann Longterm Care. 2019;27(11):e2-e3. doi:10.25270/altc.2019.11.00089

Richard G Stefanacci, DO, MGH, MBA, AGSF, CMD—Column Editor


Dr Stefanacci is the chief medical director for the managed markets agency of EVERSANA™. 


EVERSANA™, Berkeley Heights, NJ

To improve the transition for older adults from acute care into post-acute care (PAC), the Centers for Medicare & Medicaid Services (CMS) recently issued a final rule regarding discharge planning.1 CMS believes that this rule will place patients “in the driver’s seat” of their care transitions and should improve quality via requiring hospitals to provide patients access to information about PAC provider choices, for example, 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.2

The rule also advances CMS’ interoperability efforts by requiring the “seamless exchange of patient information between health care settings and ensuring that a patient’s health care information follows them after discharge from a hospital or PAC provider.”2

The current Discharge Planning Requirements (CMS-3317-F) does not directly apply to skilled nursing facilities (SNF), as it places these new discharge planning requirements on hospitals, including long-term care hospitals, critical access hospitals psychiatric hospitals, children’s hospitals, cancer hospitals inpatient rehabilitation facilities, and home health agencies, to participate in Medicare and Medicaid programs. 

This currently impacts SNFs on the receiving end, and there is a high likelihood that they will be required to adhere to these requirements in the near future. Given that many of these requirements are already considered best practice application in the SNF discharge process now, choosing to adhere to these standards ahead of being forced to may be best.

There are a great deal of opportunities for SNFs to play a greater role in the discharge process to improve both clinical and financial outcomes for all stakeholders.

A Closer Look at the New Rule

These rules require the discharge planning process to focus on a patient’s goals and treatment preferences. Additionally, hospitals are mandated to ensure each patient’s right to access their medical records in an electronic format. The rule also implements requirements from the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 that includes how facilities will account for and document a patient’s goals of care and treatment preferences.3

Most impactful to SNFs is the requirement that, when a patient is being discharged to a PAC provider, the facility’s care team needs to assist patients, their families, or the patient’s representative in selecting a PAC provider by sharing key performance data. As noted above, this data must be relevant and applicable to the patient’s goals of care and treatment preferences. CMS expects providers to document all efforts regarding these requirements in the patient’s medical record. 

To meet this requirement, many hospitals are utilizing systems like Repisodic, a patient-facing tool for enhancing transitional care. Using some basic patient information such as location, insurance, and medical condition, this tool develops a unique list of providers for each patient. Each provider profile has detailed quality metrics, accreditations, and additional information about the facility in an easy-to-understand format, so that patients and their families feel more confident making a decision about post-hospital care. 

Repisodic is promoted as assisting hospitals in reducing costs and improving PAC outcomes while increasing patient satisfaction with the discharge process. The tool can be customized according to facilities’ preferred network of providers, and guidance adheres to current CMS regulation. Working with groups like Repisodic can help ensure appropriate representation and referrals while also providing supportive technology. The platform is also designed to help reduce some tedious social worker tasks, which allows them more time to have high-value discussions with patients instead.

The facilities and home health agencies are required to send specific medical information when patients are transferred to another facility along with an evaluation of the patient’s need for post-hospital services, including, but not limited to:

  • Hospice care services and post-hospital extended care services.
  • Home health services and nonhealth care services and community-based care providers (for hospitals and critical access hospitals only).

Early Discharge Planning

All of this should begin with early discharge planning. CMS is not finalizing its proposal making hospitals develop a discharge plan for all inpatients and certain outpatients within 24 hours of admission. Instead, CMS is preserving the original proposal but with minor revisions of current requirements, ie, that hospitals identify, at an early stage, all patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning or for other patients upon request. This process also includes the discharge instructions. Previously, CMS had proposed to require hospitals to provide discharge instructions to patients who are discharged home and to send specific medical information to receiving facilities for patients who are transferred. Instead, CMS has decided that a hospital must discharge and transfer patients with all necessary medical information relevant to the patient’s illness or course of treatment, discharge goals, and treatment preferences. Despite these rules not being finalized, I would expect many hospitals and SNFs to apply these principles as a best practice.


These new rules have several critical points of impact for SNFs. As we have covered in previous LTC GPS columns, this underscores the importance for SNFs to be part of health system’s preferred PAC network.4-6 It is also important to see that the information regarding an SNF is appropriately represented to that health system’s patients.

box 1

One contributing factor in being part of a PAC preferred network is how well one’s SNF discharges its patients. As per these new rules, this means early planning of the discharge, which impacts length of stay and discharge success, and reducing hospitalizations by including discharge goals and treatment preferences, which affects success at home, sometimes through more appropriate end-of-life care. Also, as outlined in this rule, facilities must prove patient access to information/instructions on successful post-SNF care (Box 1). Facilities who follow “best practices” in the discharge process, even beyond these new CMS rules, should help ensure patients’ success at remaining at home. This will have direct impact at keeping patients and hospitals happy, which, in turn, will fill ones SNF’s beds. 


1. National Archives and Records Administration. Medicare and Medicaid programs; revisions to requirements for discharge planning for hospitals, critical access hospitals, and home health agencies, and hospital and critical access hospital changes to promote innovation, flexibility, and improvement in patient care. Federal Register. September 30, 2019. Accessed October 21, 2019.

2. Centers for Medicare & Medicaid Services. CMS’ discharge planning rule supports interoperability and patient preferences [fact sheet]. website. Published September 26, 2019. Accessed October 21, 2019.

3. Centers for Medicare & Medicaid Services. IMPACT Act of 2014 data standardization & cross setting measures. website. Updated December 11, 2018. Accessed October 21, 2019.

4. Stefanacci RG. How to be included in a health system’s preferred SNF network. Ann Longterm Care. 2017;25(5):24-26. doi:10.25270/altc.2017.10.00007 

5. Stefanacci RG. SNF medical directors’ role in utilization management. Ann Longterm Care. 2019;27(2):14-15. doi:10.25270/altc.2019.02.00061

6. Stefanacci RG. SNF success under the new hospital readmission payments. Ann Longterm Care. 2019;27(1):14-15. doi:10.25270/altc.2019.01.00056

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