11 best practices for scheduling leave from CMS



CMS has revised the guidelines for the condition of participation in discharge planning in the State Operations Manual.

The revisions show the consolidation of 24 previous output planning tags into thirteen tags, which were incorporated into the automated survey processing environment in the summer of 2012. In addition to the updated interpretation guidelines, CMS has provided advisory practices to improve patient outcomes. While these practices are not required for compliance and are not cited by surveyors, they can help improve the hospital discharge planning process, according to CMS.

CMS suggested that hospitals implement the following practices:

1. Ensure rejection practices comply with applicable federal civil rights laws and do not lead to unnecessary segregation.

2. Use, on a voluntary basis, an abbreviated post-hospital planning process for certain categories of outpatients, such as patients discharged from observation and day surgery departments and for certain categories of discharges from outpatient departments. ’emergency.

3. Develop discharge planning policies and procedures with input from hospital medical staff prior to governing body review and approval. Also get input from patients, patient advocacy groups, and other healthcare facilities and professionals who provide care for discharged patients, such as nursing homes and skilled nursing facilities, home health agencies, primary care physicians and clinics.

4. If a patient exercises the right to refuse to participate in discharge planning or to implement a discharge plan, document the refusal in the medical record.

5. Suppose each hospital patient requires a discharge plan to reduce the risk of adverse health consequences after discharge and the risk of readmission. Adapt the discharge plan to the needs of each patient.

6. Develop collaborative partnerships with post-hospital care providers, including not only skilled nursing facilities and nursing facilities, but also community service providers, to improve care transitions that could promote better patient outcomes.

7. Provide a discharge planning tool for patients and their families or other support persons to help strengthen the discharge plan, encourage patient participation in the development of the plan, and provide them with an easy-to-use guide. follow up to prepare them for a successful transition from the hospital.

8. Use a multidisciplinary team approach. Team members may include representatives from nursing, case management, social work, medical staff, pharmacy, physiotherapy, occupational therapy, respiratory therapy, dietetics and other healthcare professionals involved in the patient’s care.

9. Consider taking the following steps to improve the care transition after discharge:
• Schedule follow-up appointments with the patient’s physician or primary care practitioner and home service providers, if applicable.
• Fill prescriptions before discharge.
• Where appropriate, arrange remote monitoring technologies, such as pulse oximetry and daily weights for patients with congestive heart failure, pulse and blood pressure monitoring for heart patients and blood glucose for diabetic patients.
• Follow-up by phone calls to the patient within 24 to 72 hours after discharge.

10. Refer patients and their families to the Nursing Home Compare and Home Health Compare websites and other resources for additional information on qualified nursing facilities and Medicare-certified home care agencies, as well as nursing facilities participating in Medicaid.

11. Schedule follow-up appointments for ambulatory care services prior to discharge to reduce the likelihood of preventable readmission.

More articles on vacation planning:

Coordination of care requires streamlined communication beyond hospital walls
12 lessons on caregiver engagement in care transitions
9 steps to take with follow-up calls after discharge


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