Discharge planning is often a broken link in the chain of care for hospital patients. Older adults and others with complex care needs nearly always need follow-up after they are discharged. They’ll almost certainly have to take new medications. They may need bandages changed after surgery, or physical therapy after a stroke. Unfortunately, they and their families rarely get the information they need to manage once they get home.
That may be changing in important ways. Both states and the federal government are taking steps to require hospitals to improve their discharge plans and better communicate them to patients and their families.
In recent years, many hospitals have done this on their own. Initiatives such as Project RED (readmission discharge), or the Care Transitions Program provide clear, understandable discharge instructions; information about community resources; and involve family caregivers.
The prospect of Medicare penalties for excessive readmissions got the attention of some hospitals. They realized that the days when a hospital stopped caring for, and about, you as soon as you were rolled out the front door had come to an end.
But other facilities have not gotten the message. Now, government is starting to push them more directly to improve discharge planning.
For example, late last year California became the 18th state to enact the Caregiver Advise, Record, Enable (CARE) Act, model legislation that has been pushed by AARP throughout the country. The CARE act requires hospitals to allow a patient to identify a caregiver who would be notified of a pending discharge and be given access to appropriate discharge instructions.
Now, the federal government is cracking down harder. Last November, the Centers for Medicare & Medicaid Services (CMS) proposed detailed new regulations that would govern discharge planning and instructions for hospital and skilled nursing facility patients.