Discharge Planning

(A) There shall be written policies and procedures concerning the implementation of discharge planning services, which reflect acceptable standards of practice and compliance with applicable regulations. (B) The coordinator of discharge planning or discharge planning unit shall be responsible for the coordination of patients’ plans for continuing care in cooperation with the patient’s physician, nurse practitioner or physician’s assistant and in cooperation with the patient, and/or the family/representative as appropriate and other members of the professional staff. (C) The coordinator of discharge planning or the discharge planning unit shall establish effective systems for identifying patients in need of the hospital’s discharge planning service. The goal of these systems shall be the early, as well as ongoing, identification of patients in need of discharge planning assistance. (1) These systems shall include but not be limited to: (a) requests for discharge planning consultation from the professional staff, the patient, or his or her family/patient representative; (b) regular multidisciplinary meetings to review an individual patient’s need for continuing care; and (c) implementation of a high risk screening system to identify patients who may require discharge planning services. (2) The coordinator of discharge planning or the discharge planning unit shall be responsible for developing a written procedure describing the systems employed by the hospital to identify patients in need of discharge planning assistance. (D) Early Screening. (1) High risk case finding screening criteria shall be in writing and reflect the hospital’s experience with patients requiring post-hospital care. Criteria shall be reviewed and revised as needed but at least annually. (2) At a minimum high risk screening criteria shall include the lack of a readily available informal personal support network, e.g., family support. (3) The hospital’s high-risk screening and assessment system shall include the following provisions: (a) all patients shall be screened against the hospital’s high-risk criteria within 24 hours of admission; and (b) an initial discharge planning assessment of all patients determined to be high-risk shall take place as soon as possible, but at least within two working days of the identification of such patients. (E) Policies regarding Outpatient Discharge Planning Services. (1) The coordinator of discharge planning or discharge planning unit shall develop policies and procedures and written criteria for use in the hospital emergency service and day surgical services indicating the circumstances under which discharge planning services shall be provided for a person who is in need of post-emergency or post-ambulatory surgical planning services but not in need of in-patient hospital care. (2) Policies shall as appropriate reflect compliance with the requirements of 105 CMR 130.343(A) and (B), (D) through (H) and 130.345(B) relative to Medicare patients receiving services in emergency departments of acute hospitals. (F) Discharge planning staff shall maintain in writing a description of out-of-hospital resources, which shall be readily available to the attending physician, nurse practitioner, physician’s assistant, other members of the professional staff, the patients and their families/patient representatives. (1) Resource information available shall cover the range of services in the hospital’s primary service area that have the capability of assisting the patient and/or the patient’s family/representative in meeting the patient’s discharge needs. Where possible, information shall include admission and discharge policies and payment criteria. (2) The hospital shall employ reasonable efforts to identify and arrange for necessary post- discharge services for patients from outside of the hospital’s primary service area. (3) The hospital shall make reasonable efforts to keep resource information current. (G) In instances where the professional services of the discharge planning coordinator or unit are not required, professional staff of the appropriate professional departments shall plan for and coordinate the patient’s discharge in accordance with departmental policy outlining their responsibility.