The hospital follows its process for discharging or transferring patients.

(1)

The hospital has an effective discharge planning process that focuses on, and is consistent with, the patient’s goals and treatment preferences; makes certain there is an effective transition of the patient from the hospital to postdischarge care; and reduces the factors leading to preventable critical access hospital and hospital readmissions. Note: The hospital’s discharge planning process requires regular reevaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan is updated as needed to reflect these changes.

(2)

The hospital begins the discharge planning process early in the patient’s episode of care, treatment, and services.

(3)

As part of the discharge planning evaluation, the hospital evaluates the patient’s need for appropriate posthospital services, including but not limited to hospice care services, extended care services, home health services, and non–health care services and community-based care providers. The hospital also evaluates the availability of the appropriate services and the patient’s access to those services as part of the discharge planning evaluation.

(4)

The patient, the patient’s caregiver(s) or support person(s), physicians, other licensed practitioners, clinical psychologists, and staff who are involved in the patient’s care, treatment, and services participate in planning the patient’s discharge or transfer. The patient and their caregiver(s) or support person(s) are included as active partners when planning for postdischarge care. Note 1: The definition of “physician” is the same as that used by the Centers for Medicare & Medicaid Services (refer to the Glossary). Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The hospital notifies the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and reasons for the move. The notice is in writing, in a language and manner they understand, and includes the items described in 42 CFR 483.15(c)(5). The hospital also provides sufficient preparation and orientation to residents to make sure that transfer or discharge from the hospital is safe and orderly. The hospital sends a copy of the notice to a representative of the office of the state's long-term care ombudsman.

(5)

The hospital performs a discharge planning evaluation and creates a discharge plan for those patients it identifies at an early stage of hospitalization are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning or at the request of the patient, patient's representative, or the patient’s physician. Note 1: The discharge planning evaluation is completed in a timely manner so that appropriate arrangements for posthospital care are made before discharge and unnecessary delays in discharge are avoided. Note 2: The discharge planning evaluation is performed and subsequent discharge plan is created by, or under the supervision of, a registered nurse, social worker, or other qualified person.

(6)

The hospital discusses the results of the discharge planning evaluation with the patient or their representative, including any reevaluations performed and any arrangements made.

(7)

The hospital assists the patient, their family, or the patient’s representative in selecting a post–acute care provider by using and sharing data that includes but is not limited to home health agency, skilled nursing facility, inpatient rehabilitation facility, and long-term care hospital data on quality measures and resource-use measures. The hospital makes certain that the post–acute care data on quality measures and resource-use measures is relevant and applicable to the patient’s goals of care and treatment preferences.

(8)

For hospitals that use Joint Commission accreditation for deemed status purposes: The patient’s discharge plan includes a list of home health agencies, skilled nursing facilities, inpatient rehabilitation facilities, or long-term care hospitals that are available to the patient, participating in the Medicare program, and serving the geographic area in which the patient resides (as defined by the home health agency or, in the case of a skilled nursing facility, inpatient rehabilitation facility, or long-term care hospital, in the geographic area requested by the patient). The hospital documents in the medical record that this list was presented to the patient or the patient’s representative. Note 1: Home health agencies must request to be listed by the hospital. Note 2: This list is only presented to patients for whom home health care, posthospital extended care services, skilled nursing, inpatient rehabilitation, or long-term care hospital services are identified as needed.

(9)

For hospitals that use Joint Commission accreditation for deemed status purposes: For patients enrolled in managed care organizations, the hospital makes patients aware of the need to verify with their managed care organization which practitioners, providers, or certified suppliers are in the managed care organization’s network. If the hospital has information on which practitioners, providers, or certified suppliers are in the network of the patient’s managed care organization, it shares this information with the patient or the patient’s representative.

(10)

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital informs the patient or the patient’s representative of their freedom to choose among participating Medicare providers and suppliers of postdischarge services and, when possible, respects the patient’s or their representative’s goals of care and treatment preferences, as well as other preferences when they are expressed. The hospital does not limit the qualified providers or suppliers that are available to the patient.

(11)

For hospitals that use Joint Commission accreditation for deemed status purposes: The discharge plan identifies any home health agency or skilled nursing facility in which the hospital has a disclosable financial interest and any home health agency or skilled nursing facility that has a disclosable financial interest in a hospital. Note: Disclosure of financial interest is determined in accordance with the provisions in 42 CFR 420, subpart C, and section 1861 of the Social Security Act (42 U.S.C. 1395x).

(14)

The hospital assesses its discharge planning process on a regular basis, as defined by the hospital. The assessment includes an ongoing, periodic review of a representative sample of discharge plans, including plans for patients who were readmitted within 30 days of a previous admission, to make certain that the plans are responsive to patient postdischarge needs.

(15)

The hospital has written policies and procedures for transferring patients under its care (inclusive of inpatient services) to the appropriate level of care (including to another hospital) as needed to meet the needs of the patient. The hospital also provides annual training to relevant staff regarding the hospital policies and procedures for transferring patients under its care.