D. Leaving the Hospital

• Library: A Practical Guide to Elder and Special Needs Law in South Carolina (SCBar) (2021 Ed.)

D. LEAVING THE HOSPITAL

1. Discharge Plan

Discharge planning is routine for all patients. However, having a specific and effective discharge plan for elder or special needs patients is incredibly important to ensure a smooth transition of patient care. A discharge is "a formal release of an enrollee from an inpatient hospital." 42 C.F.R. § 422.620. The health care team must collaborate to create a discharge plan that ensures patients and caregivers are aware of the patient's health care needs, care plans, and necessary continued health care services. Alfred J. Chiplin, Jr., Breathing Life into Discharge Planning, 13 Elder L. J. 1 (2005). Ensuring patients have access to health care resources, education, and counseling will ensure they are taking the proper precautions when departing the hospital. Prior to discharge, the health care team, usually consisting of an M.D./D.O./N.P/P.A., nurses, and social workers, will create a plan that establishes where the patient will go upon discharge, specific care needs, any new medications or prescriptions, medical equipment for in-home care, activities patient is capable of participating in, and health care professionals needed to see for follow up. Denise M. Goodman, Discharge Planning, The Journal of the American Medical Association (2013). If applicable, the health care team should additionally ensure the proper transfer is ready to be executed upon discharge. Transfer locations could include a long- or short-term care facility, skilled nursing facility, rehabilitation facility, or home health care program. Alfred J. Chiplin, Jr., Breathing Life into Discharge Planning, 13 Elder L. J. 1 (2005). When leaving the hospital, the patient should make sure they have copies of the treatment received at the hospital and the discharge plan instructions. Denise M. Goodman, Discharge Planning, The Journal of the American Medical Association (2013). If performed thoroughly, discharge planning can reduce the length of the hospital stay, decrease readmission to the hospital, and improve patient outcomes. Alfred J. Chiplin, Jr., Breathing Life into Discharge Planning, 13 Elder L. J. 1 (2005).

a. Centers for Medicare and Medicaid Services and Discharge Planning

Hospitals that participate in Medicare and Medicaid must have in effect a discharge planning process that applies to all patients. The hospital's policies and procedures must be specified in writing. 42 C.F.R. § 482.43.

The following are the discharge planning conditions of participation required by federal law:

(a) Standard: Identification of patients in need of discharge planning. The hospital must identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning.
(b) Standard: Discharge planning evaluation.

(1) The hospital must provide a discharge planning evaluation to the patients identified in paragraph (a) of this section, and to other patients upon the patient's request, the request of a person acting on the patient's behalf, or the request of the physician.
(2) A registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise the development of, the evaluation.
(3) The discharge planning evaluation must include an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services.
(4) The discharge planning evaluation must include an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment.
(5) The hospital personnel must complete the evaluation on a timely basis so that appropriate arrangements for

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