CMS: Hospital-To-Home Discharge Process Still Plagued By Poor Communication, Incomplete Patient Information

Patient transitions from the hospital to post-acute care providers, including home health agencies, continue to be plagued by incomplete medical records and missing information.

Gaps in post-acute care transitions are so common, in fact, that the U.S. Centers for Medicare & Medicaid Services (CMS) is calling out hospitals for putting patients and their families in harm’s way.

“CMS has identified areas of concern related to missing or inaccurate patient information when a patient is discharged from a hospital,” a recent memo from the agency sent to state survey agency directors notes.


A lack of communication between referring hospitals and home health agencies is not a new trend.

University of Colorado Anschutz Medical Campus researchers reported in a 2019 study, for instance, that more than half of the home health clinicians they surveyed said hospitals did not adequately prepare patients for home health upon discharge. Another study published in 2022 likewise documented challenges with hospital-to-home transitions, with University of Michigan researchers noting that patients were more likely to suffer a setback requiring another hospitalization when post-acute care handoffs weren’t as comprehensive as they should be.

Other research has revealed similar transition gaps for patients going from hospitals to skilled nursing facilities (SNFs).


“When a patient is discharged from a hospital, it is important to provide their post-acute provider and caregivers as applicable with the appropriate patient information related to a patient’s treatment and condition in order to decrease the risk of readmission or an adverse event,” the recent CMS memo advises.

The agency has identified several areas where hospitals are frequently failing to share information with their post-acute care referral partners.

One common pain point has been hospitals sharing an incomplete list of all the medications that patients had been prescribed during, and prior to, their hospital stay. This makes medication management difficult for post-acute care providers while also putting the patient at risk.

Hospitals also frequently omit important information related to any wounds, such as pressure ulcers, that patients experienced before or during their hospital stay, according to CMS. Hospitals all too often fail to share the behavioral health status of patients – and how they managed any serious mental illness (SMI) or substance use disorder (SUD) conditions – as well.

“Information related to patient’s acute condition may be included, but information related to the patient’s underlying diagnoses of SMI and/or SUD is not included,” the memo continues.

Hospitals additionally don’t do a good job relaying patients’ goals of care, or their end-of-life care wishes, according to CMS.

CMS regulations require hospitals to “have an effective discharge planning process that focuses on the patient’s goals and treatment preferences.” The process must include the patient and his or her caregivers as active partners in the discharge planning for post-discharge care.

Hospitals are also required to refer patients to post-acute care with “all necessary medical information pertaining to the patient’s current course of illness and treatment.”

Prior to 2020, home health agencies had steadily grown their share of referrals coming from community-based sources. The implementation of the Patient-Driven Groupings Model (PDGM) set higher payment rates for institutional referrals, however, making hospital, SNF and other facility-based referrals critical for some agencies’ bottom lines.

In a survey of more than 150 home health professionals conducted by Home Health Care News and Forcura, 27% of respondents said their organizations had a majority of institutional referrals. Another 32% said their referral sources were “somewhat more institutional than community-based.”

In the same survey, 27% of respondents said poorly managed or delayed care transitions of patients had a “very” negative impact on care. Another 17% said poorly managed or delayed care transitions had an “extremely” negative impact on care.

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