OpenPlacement Blog

Discharge Planning: A Checklist For Hospitals and Other ACOS

checklist-300x199Although the current hospital discharge planning process meets the needs of many inpatients released from the acute care setting, some discharges result in less-than-optimal outcomes for patients including complications and adverse events that lead to hospital readmissions. Reducing avoidable hospital readmissions and patient complications presents an opportunity for improving the quality and safety of patient care while lowering health care costs (Services, 2015).

On October 29, 2015, the Centers for Medicare & Medicaid Services issued a proposal to revise the discharge planning requirements hospitals and ACOs must meet in order to participate in Medicare and Medicaid programs. The proposed rule can be read here: This proposal would also implement the discharge planning requirements of the IMPACT act of 2014, which aims to improve consumer transparency and beneficiary experience during the discharge planning process. Specifically, the IMPACT act calls for "hospitals, including inpatient rehabilitation facilities and long-term care hospitals, critical access hospitals, and home health agencies [...] to develop a discharge plan based on the goals, preferences, and needs of each applicable patient. (, 2015)" Combining the requirements of the new proposed rule with the IMPACT act, this discharge planning checklist was compiled and adapted using the Department of Health and Human Service's Discharge Planning Booklet. Hereafter any reference to "the patient" will represent either the patient themselves, the patient's family, caregiver, or any individual acting on the patient's behalf.

While this list incorporates CMS's suggested discharge checklist, each hospital or  ACO should compile their own checklist depending on their specific developed protocols and needs.

- Within 24 hours of admission/registration, you must develop a discharge plan including:

  • A summary of the patient’s stay

  • Treatments and pain management

  • Symptoms

  • Whether the patient was in seclusion or physically restrained

  • The patient’s bio-psychosocial needs™

  •  Medication/therapy management needs™

  • Whether there are any necessary modifications needed for the patient's home or any specialized medical equipment needed to allow the patient to self- care at home and, if necessary, how the patient may acquire such equipment or modifications

  • Whether the patient has the ability to self-care and, if not, whether family, friends, or other caregivers are willing/able to provide care

  • The availability of community-based services

  •  If admitted from a facility (such as a NF or SNF), whether the patient wishes to return to that facility and its ability to provide for the patient’s car

  •  Relevant information obtained from the patient, such as financial information, health insurance, or prescription coverage

  • The patient’s understanding of his/her discharge need

- Discuss results of the discharge planning evaluation with the patient

- Provide the patient with a list of Medicare-certified Home Health Agencies (HHA) or Skilled Nursing Facilities (SNF) that serve the geographic area where he/she resides, participate in the Medicare Program, and request inclusion on the list. Remember that under Section 1861(ee) of the Social Security Act, you are prohibited from limiting or steering the patient to any particular HHA or SNF. You must identify those HHAs and SNFs in which you have a disclosable financial interest or HHAs or SNFs that have such an interest in you

- Arrange necessary AAC hospital/PAC facility services and care

- Educate the patient about his/her AAC hospital/PAC facility care plans. Utilize teach back to ensure that individuals who will be providing care know and can demonstrate and verbalize the patient’s care needs

- Arrange transfer to the chosen facility including referrals (physicians, equipment, etc) and access to medications. This information must go with the patient if he/she transfers to another inpatient or residential health care facility

-  Within 7 days after discharge or before the first appointment for ambulatory services, the patient's medical information should be transmitted to the patient’s physician

- Provide the patient with written and verbal instructions to prepare him/her for their AAC hospital/PAC facility care, including post-discharge options; medications to continue or discontinue and how to use them properly after discharge; what to expect after discharge; and what to do if concerns, issues, or problems arise

- Document the following in the patient’s clinical record: discharge planning evaluation activities, that the results of the discharge planning evaluation were discussed with the patient, and, if applicable, the refusal of the patient to participate in discharge planning or comply with a discharge plan

- Conduct a discharge planning reassessment. This reassessment determines whether the discharge planning process was responsive to patient's post-discharge needs

"There were over 35 million hospital discharges in the United States in 2010. Among Medicare patients, almost 20 percent who are discharged from a hospital are readmitted within 30 days (Alper, O'Malley, & Greenwald, 2016)." Improper or inefficient patient transfers can not only cause patient readmission, but can also result in avoidable complications, adverse events, and increased costs to the hospital. In the interest of reducing these readmission rates and gaining better patient outcomes, CMS strives to reduce the amount of variation between caregivers. When all hospitals, ACOs, and PAC facilities are on the same page with the same requirements, transitions can be smoother, less stressful for the patient and, most importantly, more accurate. Better communication means better health outcomes and better health outcomes are a positive for both patients and hospitals.

For more information and a patient-centered checklist download:

Alper, E. M., O'Malley, T. A., & Greenwald, J. M. (2016). Hospital discharge and readmission. UpToDate. (2015). Discharge Planning Proposed Rule Focuses on Patient Preferences. Centers for Medicare & Medicaid Services.

Services, C. f. (2015). Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies. Baltimore, MD: Department of Health and Human Services.

Services, D. o. (2014, October). Discharge Planning. Discharge Planning Booklet . Medicare Learning Network.

Your Discharge Planning Checklist. (2015). Your Discharge Planning Brochure 2015 . Centers for Medicare & Medicaid Services.