CMS’ Discharge Planning Rule Supports Interoperability and Patient Preferences

CMS’ Discharge Planning Rule Supports Interoperability and Patient Preferences

The Centers for Medicare & Medicaid Services (CMS) issued a final rule that empowers patients preparing to move from acute care into post-acute care (PAC), a process called “discharge planning.” The rule, effective November 29, 2019, 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. The rule also advances CMS’s historic interoperability efforts by requiring the seamless exchange of patient information between healthcare settings, and ensuring that a patient’s healthcare information follows them after discharge from a hospital or PAC provider.

The final rule (Revisions to Discharge Planning Requirements [CMS-3317-F]) revises the discharge planning requirements that hospitals (including long-term care hospitals, critical access hospitals [CAHs] psychiatric hospitals, children’s hospitals, and cancer hospitals), inpatient rehabilitation facilities, and home health agencies must meet to participate in Medicare and Medicaid programs. It requires 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 Act of 2014 (IMPACT Act) that includes how facilities will account for and document a patient’s goals of care and treatment preferences.). Additionally, if a patient is being discharged to a PAC provider, the rule requires the facility’s care team to assist patients, their families, or the patient’s representative in selecting a PAC provider by sharing key performance data. 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. 

CMS notes that hospitals and CAHs are already conducting most of the revised discharge planning requirements, with the exception of the discharge planning requirements of the IMPACT Act. The facilities and home health agencies are also 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 non-health care services and community based care providers (for hospitals and critical access hospitals only).

For more information, please visit:

To view the final rule (CMS-3346-F), please visit:


Questions? Contact Laura Hofmann, MSN, RN
Director of Clinical and Nursing Facility Regulatory Services
e: – c: 360.691-9281