CMS guidelines mandate improved patient engagement, choice, and continuity of care across hospital settings.

In an effort to improve care transitions, the Centers for Medicare & Medicaid Services (CMS) in September announced a new discharge planning rule that outlines requirements for hospitals and home health agencies (HHAs). The rule is designed to make the discharge process more patient- centered and data-driven. Guidelines were created in part to simplify the process for patients to access their medical records and ensure that medical records follow them across the continuum. The rule goes into effect November 29, 2019.

Patient-first approach: 4 things to know

To meet the new discharge planning requirements, hospitals will need to:

  1. Identify and assess at-risk patients, create discharge plans, and evaluate patients for discharge planning if patients or physicians request it. 
  2. Send detailed medical information to post-acute care (PAC) facilities and home-based providers after completing patient transfers.
  3. Provide patients and caregivers with access to medical records in their requested format, including electronic documents.
  4. Record all efforts to meet these requirements in patients’ medical records. 

Dina helps hospitals meet new requirements

Dina’s digital care coordination platform helps hospitals meet these new requirements by providing:

  • PAC provider information including an overview of all network providers, and an automatically tailored list based on patient-specific criteria like insurance coverage, proximity to the patient, quality ratings, preferred network status, and other considerations. 
  • In-workflow access to CMS star ratings, facility-specific clinical measures, patient-fall ratios, hospital readmissions rates, and other data to help hospital discharge teams match patients with the right providers and levels of care.
  • Tools to empower discharge planning teams to share goals and treatment preferences with downstream partners, including home and family caregivers. Entire care teams can electronically gather and share necessary information within a HIPAA-compliant platform to ensure successful patient transitions. 
  • Tools to share information with patients and educate them on their discharge plans and PAC provider options. Patients can request additional documentation from care teams through the platform. 
  • Historical data to audit and review transitions at any point.


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