and services, go to The financial costs are summarized in Table 1.Start Printed Page 51879, Table 1—Section-By-Section Economic Impact Estimates. We therefore, are not finalizing this requirement as proposed and we refer readers to section II.C.3 of this final rule for a detailed discussion of this decision. Executive Order 13563 on Improving Regulation and Regulatory Review expressly states, in its section on retrospective review, that “agencies shall consider how best to promote retrospective analysis of rules that may be outmoded, ineffective, insufficient, or excessively burdensome, and to modify, streamline, expand, or repeal them in accordance with what has been learned.” This final rule applies that mandate to discharge planning. We expect hospitals and CAHs to include the patient and the patient's caregiver/support person, where applicable, in the planning for a patient's post-discharge care. Therefore, we do not believe an additional delay in the effective date for hospitals and CAHs is necessary. We are continuing to consider comments on the remaining portion of the Hospital Innovation proposed rule, and we will respond to those comments when we finalize that rule in future rulemaking. We believe that this information should be conveyed upon discharge or transfer since such information is clearly necessary medical information and should be transferred with the patient. The President of the United States communicates information on holidays, commemorations, special observances, trade, and policy through Proclamations. Medicare and Medicaid programs; revisions to conditions of participation for hospitals--HCFA. One commenter stated that we have underestimated the time required of an RN or physical therapist to complete the HHA standards finalized here. Specifically, Congress directed that ONC “. Response: Issues of caregiver willingness and ability are already addressed as part of the comprehensive assessment requirements at § 484.55(c)(6). However, we believe that provider staff are capable of complying with the requirement to assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that Start Printed Page 51844includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. Relevant information about this document from Regulations.gov provides additional context. CMS proposes to require that home health agencies develop and implement an effective discharge planning process as a Medicare Condition of Participation (CoP). Sending the discharge summary to the follow-up care practitioner or facility was set forth in the HHA CoPs final rule, and we did not propose to modify that requirement. These goals and treatment preferences would be taken into account throughout the entire discharge planning process. One commenter stated that PDMPs should only apply to the prescription of controlled substances until the universal use of PDMPs is better understood. This final rule focuses on reforms to discharge procedures that will enhance patient health and safety by filling gaps, while providing appropriate flexibility. Therefore, we are not required to estimate the public reporting burden for information collection requirements for that specific element of this final rule in accordance with chapter 35, title 45 of the United States Code. Some commenters stated that the extensive list would not improve the transition of patient care. The statutory timing of the IMPACT Act varies for the standardized assessment data described in subsection (b) of the Act, data on quality measures described in subsection (c) of the Act, and data on resource use and other measures described in subsection (d) of section 1899B of the Act. Currently, the CoPs at § 485.631(c)(2)(ii) provide that a CAH must arrange for, or refer patients to, needed services that cannot be furnished at the CAH. We estimate that an administrator will spend 8 hours on this activity for a total of 8 hours per hospital at a cost of $1,680 (8 hours × $210 for an administrator's hourly salary cost), together with an RN or equivalent for an additional 8 hours at a cost of $568 (8 hours × $71 for an RN salary cost). In addition, some commenters stated that PDMPs could work if there were a national or standardized PMDP database. Another commenter recommended that the requirements in this rule align with current health IT certification requirements, in order to eliminate redundancy. Of course, we encourage providers to use follow-up procedures they find cost-effective for particular categories of patients. The Medicare Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) set forth the federal health and safety standards that providers and suppliers must meet to participate in the Medicare and Medicaid programs. We also proposed to require that the hospital's discharge planning process ensure an ongoing patient evaluation throughout the patient's hospital stay or visit in order to identify any changes in the patient's condition that would require modifications to the discharge plan. This emphasis on reducing preventable readmissions, especially for the most vulnerable patient populations, remains a high priority for CMS. We also agree that the proposed terminology lacked clarity in a manner that could make surveying for compliance difficult and potentially inconsistent. While some commenters supported the proposed list of elements and offered suggestions for additional elements, most commenters believed that the list of required necessary medical information was overly prescriptive, excessively extensive, time consuming, duplicative, and burdensome. We are committed to publishing a final rule that provides clear health and safety standards for hospitals, HHAs, and CAHs. In the Discharge Planning proposed rule, we solicited comments on the timeline for implementation of the proposed CAH discharge planning requirements (80 FR 68139). If the patient's stay was less than 24 hours, the discharge-related needs of the patient would be identified prior to the patient's discharge home or transfer to another facility and without unnecessarily delaying the patient's discharge or transfer. Any other information necessary to ensure a safe and effective transition of care that supports the post-discharge goals for the patient. In these cases, we expect that the hospital will provide a list of PAC providers that are available to provide the services requested by the patient. However, another commenter believed it may not be necessary to forward such information to the health care practitioner. L. 104-4), Executive Order 13132 on Federalism (August 4, 1999), the Congressional Review Act (5 U.S.C. 804(2)), and Executive Order 13771 on Reducing Regulation and Controlling Regulatory Costs (January 30, 2017). The commenter recommended that CMS modify the language used in the rule and clarify that the patient's goals and preferences must be considered during the discharge planning process, but that it is ultimately the decision of the practitioner responsible for the care of the patient whether the goals and preferences can be incorporated into the discharge plan. Given the potential benefits of PDMPs as well as some of the challenges noted in the proposed rule, we solicited comments on whether providers should be required to consult with their state's PDMP and review a patient's risk of non-medical use of controlled substances and substance use disorders as indicated by the PDMP report. This reduction of costs by more than half reflects some downward re-estimates, but mainly our efforts to remove overly prescriptive and costly process requirements that had originally been proposed. We did not receive any comments on this standard. Comment: Commenters supported the proposal to require the discharge plan to identify any HHA or SNF to which the patient is referred in which the hospital has disclosable financial interest. Mandate that providers collaborate and coordinate with community based organizations on the availability of community supports at discharge. We proposed at § 485.642(c)(7) to require that the patient's discharge plan address the patient's goals of care and treatment preferences. Executive Order 13771, titled Reducing Regulation and Controlling Regulatory Costs, was issued on January 30, 2017 and requires that the costs associated with significant new regulations “shall, to the extent permitted by law, be offset by the elimination of existing costs associated with at least two prior regulations.” This final rule imposes costs and therefore is considered to be a regulatory action under Executive Order 13771. Removing proposed § 485.642(c), (d), and (e) and replacing these standards with revisions and redesignating as § 485.642(b) titled “Discharge and transfer of the patient and provision and transmission of the patient's necessary medical information.” The final standard at § 485.642(b) incorporates and combines revised provisions from the proposed requirements at § 485.642(c), (d), and (e). Accordingly, the usual practice of HHS is to treat all providers and suppliers as small entities in analyzing the effects of our rules. Nor are we required to undergo the specific public notice requirements of the PRA. This information is not part of the official Federal Register document. Another commenter stated that hospitals should be required to provide lists of all providers and services available to patients upon discharge. 4. informational resource until the Administrative Committee of the Federal However, we would expect that CAHs would not make decisions on PAC services on behalf of patients and their families and caregivers and instead focus on person-centered care to increase patient participation in post-discharge care decision making. This final rule establishes as a condition of participation (which facilities must meet in order to participate in the Medicare and Medicaid programs) the requirement that hospitals have a discharge planning process for patients who require such services and specifies the elements of that process. If you are using public inspection listings for legal research, you It is not an official legal edition of the Federal Among the categories recommended were physical therapy, nutrition, mental health, dental, durable medical equipment, and others. Response: We do not believe that it is appropriate to require hospitals to use certain specialty practitioners in any particular step of the discharge planning process. Discharge to Home (Proposed § 482.43(d)), 7. Providers may give this information to patients if they choose. For example, the final HHA CoP final rule requires HHAs to communicate with all relevant parties, including physicians who are involved in the patient's HHA plan of care, whenever there are revisions related to the plan for patient discharge (§ 484.60(c)(3)(ii)). Commenters recommended that specific information be determined by hospitals or CAHs and that only essential information be sent with the patient in the case of a transfer. We remind hospitals that they can find more information on community-based services and community-based organizations at http://www.acl.gov/​. This requirement will be included in § 482.43(a)(3). documents in the last year. 804(2). Comment: One commenter stated that we should develop consistent standards of communication, information sharing, and discharge planning across the entire acute and post-acute care continuum. We proposed at § 485.642(b) to establish a new standard, “Applicability,” to require the CAH's discharge planning process to identify the discharge needs of each patient and to develop an appropriate discharge plan. Comment: One commenter stated that many rural Americans live in areas with limited health care resources, restricting their available options for care, including post-acute care options. This repetition of headings to form internal navigation links This document announces the extension of the timeline for publication of the “Medicare and Medicaid Program; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies” final rule. We proposed at § 485.642(c)(3) that the CAH's discharge planning process require regular reevaluation of patients to identify changes that require modification of the discharge plan. However, we clarify that we did not propose PDMP requirements, and solely solicited comments in the proposed rule on whether provider consultations with PDMPs during the discharge planning process should be required. In accordance with the provisions of Executive Order 12866, this rule was reviewed by the Office of Management and Budget. Establishing a specific list of information that must be shared from an HHA to another health care provider creates a risk of simultaneously overburdening HHAs with elements that are not applicable and leaving out elements that are critical to assuring a safe and effective care transition in any given situation. This information would be part of the medical record where the device was implanted. This table of contents is a navigational tool, processed from the Except for comments specific to the Hospital Innovation proposed rule, all comments discussed here were submitted in response to the Discharge Planning proposed rule. We also encourage providers to refer to www.medicare.gov for additional resources and help. (7) The hospital must assess its discharge planning process on a regular basis. Equally importantly, the necessity of meeting this new legislative requirement provides an opportunity to meet the requirement for retrospective review of an important set of regulatory requirements that have not been systematically reviewed in decades. We expect the hospital to address in its discharge planning policy cases in which there are no PAC providers within a patient's managed care network, to the extent that this information is known. Require providers to give the caregiver a copy of the final discharge plan, since “informed of the final plan” is not defined. L. 105-33), codified as 1861(ee)(2)(D) of the Act, provided that the hospital discharge planning evaluation include an evaluation of the patient's likely need for post-hospital services and the availability of those services, “including Start Printed Page 51862the availability of home health services through individuals and entities that participate in the program under this title and that serve the area in which the patient resides and that request to be listed by the hospital as available.” We have interpreted this provision to require that hospitals need only indicate the availability of home health services provided by HHAs that request to be listed in the discharge plan, as opposed to the universe of individuals and entities that participate in the program. Response: While we have revised and relocated some of the proposed requirements in this final rule, we have essentially retained (with some clarifying modifications as well as the addition of some important elements of the proposed requirements for this section) the current requirement that the hospital must transfer or refer the patient, along with his or her necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care upon discharge. Response: The CAH discharge planning requirements are intentionally very similar to those of the hospital discharge planning requirements. However, other commenters stated that the proposed requirements that a hospital must consider in evaluating a patient's discharge needs are overly prescriptive and overly detailed. Laboratory and diagnostic tests and results: They would not typically be part of the home health medical record. Some commenters explained that there are additional challenges for providers whose patients cross multiple state lines, since PDMPs vary by state. Aside from the certification of EHR technology that was finalized in other rules, we did not propose standardized methods of communication and information sharing between different health care provider types as part of the Conditions of Participation. We believe that the overall involvement of the patient and caregivers, as set forth in §§ 482.43 and 485.642, in addition to the already established practice of providing discharge instructions appropriate to each patient as is the current standard of care, will ensure appropriate communication between providers, patients, and caregivers throughout the discharge planning process. We assume 4 hours of legal time at $136 an hour for a cost of $544 and 4 hours of physician time at $203 an hour for a cost of $812. Because of the important role that community based organizations play, we strongly encourage hospitals to develop collaborative partnerships with providers of community-based services. We proposed at § 482.43(c), “Discharge planning process,” to require that hospitals implement a discharge planning process to begin identifying, early in the hospital stay, the anticipated post-discharge goals, preferences, and needs of the patient and begin to develop an appropriate discharge plan for the patients identified in proposed § 482.43(b). We believe these requirements will afford patients the opportunity to Start Printed Page 51840be active participants in the discharge planning process. However, we note that Medicare and Medicaid participating facilities are surveyed regularly to assure quality, and we believe that Medicare facilities in good standing can be trusted to provide services safely. (5) Any discharge planning evaluation or discharge plan required under this paragraph must be developed by, or under the supervision of, a registered nurse, social worker, or other appropriately qualified personnel. We expect that the CAH will identify personnel qualified to conduct this activity as part of its discharge planning process. In addition, we continue to believe in the importance of person-centered care during the discharge planning process. 300jj-11(c)), requires HHS to take steps to advance the electronic exchange of health information and interoperability for participating providers and suppliers in various settings across the care continuum. The requirement at § 485.642(a)(8), which is associated with the IMPACT Act, will require CAHs to review their current policies and procedures and update them so that they comply with the new requirements, which will be a one-time burden on the CAH. We would expect that the CAH would be available to discuss and answer patients and their caregiver's questions about their post-discharge options and needs. documents in the last year, 236 We also expect that hospitals are providing any necessary requested information to follow up providers. As required by the IMPACT Act, HHAs must take into account data on quality measures and resource use measures during the discharge planning process. Additionally, we would also like to point out that in those hospitals and CAHs where there are multiple licensed and qualified practitioners responsible for the care of the same patient, delay of the discharge, and transfer or referral where applicable, of the patient, along with his or her necessary medical information, should not occur as a result of “waiting” for a specific provider's signature, either written or electronic, on the discharge order and the discharge or transfer summary for the patient. 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