Physician Advisory

Dr. Ronald HirschAugust 11, 2020

Clinical Practice Today: What Should Physicians Know About the New CMS Rule on Discharge Planning?

In September 2019, the Centers for Medicare & Medicaid Services (CMS) released a new rule on discharge planning, which stems from the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. Much less prescriptive than the requirements originally proposed, the final rule increases access to information and resources that can help physicians provide high-quality care and help patients make more informed care decisions. According to CMS, the final rule is designed to “focus less on prescriptive and burdensome process details, and more on patient outcomes and treatment preferences.”


The goals of the rule center on empowering patients, improving care transitions, and, ultimately, improving quality of care by increasing exchange of and access to information. The new requirements build on the efforts of the Department of Health and Human Services to enhance interoperability and facilitate information exchange as well as emphasize patient-centered, value-based care. CMS also hopes that the requirements will encourage competition among post-acute care
facilities, thereby improving care.


Specifics of the New Rule

The new rule—which went into effect on November 29, 2019—extends discharge planning requirements to home health agencies and critical access hospitals (other hospitals were already required to follow these regulations) and bolsters requirements for information sharing. Among the highlights:


  • Hospitals and critical access hospitals must identify patients who are likely to suffer adverse health consequences after discharge and develop
    customized discharge plans for these patients. They must also develop a plan when requested by physicians, family members/caregivers, and patients.
  • Discharge plans must include an assessment of patients’ needs for post-hospital services as well as the availability of those services and patients’ ability to access them. Plans must include CMS “Compare” quality and resource use data on post-acute care providers ( and consider patients’ goals of care and treatment preferences.
  • Providers must transfer all necessary medical information (i.e., current course of illness or treatment, post-discharge goals of care, treatment preferences) to the appropriate post-acute care service providers and suppliers, including outpatient service providers and practitioners, responsible for follow-up or ancillary care.


“The most significant change is that hospitals must provide quality and resource use data to patients who will be receiving home care or transferring to a post-acute provider location, which includes skilled nursing facilities, long-term acute care hospitals, and acute inpatient rehabilitation facilities,” says Ronald Hirsch, MD, FACP, vice president of the Regulations and Education Group at R1 Physician Advisory Services, a company that helps physicians and case management workers navigate regulatory requirements. “From an operational standpoint, this has exponentially increased the amount of information that is required and must be presented,” he says.


Although this information can assist patients and family members in making more informed decisions, it may also lead to more questions. Quality and resource use data can be challenging to decipher and put into context. If a physician recommends a provider who does not score well according to a Compare website, patients may question that recommendation, Hirsch says, adding that this scenario will be more common for hospital-based physicians.


He also points to the continued growth of Medicare Advantage plans in many parts of the country, which may limit patients’ choice of post-acute providers and further complicate the conversations around post-acute care. “Physicians must be very careful not to ‘make promises’ to patients that cannot be fulfilled because of payer contracts,” Hirsch says.


Smoother Transitions

The new rule aims to facilitate care transitions and prevent unnecessary readmissions by requiring increased information sharing between hospitals and post-acute care providers, including community-based


“One of the keys to preventing readmissions is ensuring that the patient is seen quickly in the community,” says Hirsch. If the physician does not have complete information during the patient visit or is not aware that the patient has been discharged, continuity of care can be compromised, and the readmission risk can increase.


“The advent of the hospitalist model has led to somewhat of a disconnect between the patient’s care in the hospital and the information available to the PCP,” he explains. “If the PCP does not have a summary of the patient’s hospital care, the results of any testing, and any medication changes, then the visit is not as productive as it could be,” he says.


Ideally, the discharge summary should be complete and ready to transfer to the post-acute care or community-based physician before the patient leaves the hospital, Hirsch says. If results are still pending at discharge, they should be sent to the PCP for follow-up once available. Hirsch suggests that physicians keep track of delays between patient discharge and release of discharge summary and address the delays with those who do not release information to post-acute providers in a timely manner.


Hirsch applauds the CMS provision that requires providers to grant patients access to their medical records, advising providers to be especially careful when using templates or a copy-and-paste method to build the record.

Although some facilities may find it challenging to provide this additional information, Hirsch is glad to see these issues addressed. “The goal is to make patients more active in every step of their health care,” he says,  from deciding on their treatment plan to choosing from whom and where they want to receive their care.”