Healthify Blog

Post Discharge Planning: Taking Patients from Referrals to Results

At the end of October, the Centers for Medicare and Medicaid Services (CMS) proposed revisions to discharge planning requirements for hospitals, inpatient facilites, and home health agencies. The new model requires healthcare providers to share quality and resource utilization data on post-acute care providers with patients. The goal of this CMS reform is to ensure that post-acute care referrals meet patients' own goals and expectations of care.

The objective of this reform is laudable. It is a step in the right direction to better incorporate post-discharge planning into the intake process, creating a plan of action that the patient can assess from the very beginning of their hospital stay. Furthermore – and this is the part that excites me – hospitals will have to forward all of the patient's relevant medical information to the receiving institution and establish a process for following up. How exciting is that!? 

Now, there are a number of fantastic software companies out there that deal exclusively in helping hospitals manage discharge planning and referrals to post-acute providers like our friends at Aidin. The reason this news excites the folks here at Healthify so much is simple: Any step that healthcare takes towards greater patient involvement in post-discharge planning is a tremendous step forward for patient-centered care. Giving patients access to quality and resource utilization metrics is key to helping them make an informed decision.

I applaud CMS on proposing this revision to discharge planning guidelines, but I encourage them to go even further. A Medicaid and Medicare beneficiary can receive all the post-acute care in the world, but if they're dealing with multiple social determinants of health (hunger, homelessness, substance abuse, depression, stress, etc.), they're going to need discharge plans that include food options, dependency treatment, mental health counseling, or a safe place to stay. Community resources work hard to provide these services to the community. Resources can be easily located by using a resource database with referral tracking built in like Healthify, making the development of a social determinants-centered care plan easy for the provider.

To CMS we say give patients even more choice. Use the power and prestige of healthcare to take away some of the stigma of treating social ailments. I guarantee we'll see improvements in readmission rates post-discharge. 

Topics: healthcare delivery social determinants of health community resources