The Discharge Hand-Off: What the Next Outpatient Provider Needs

A discharge plan is only as good as the first outpatient visit that follows it. For discharge planners, case managers and emergency department social workers, the question is what the next provider needs in hand. Here is what the federal discharge planning rule asks hospitals to send, why readmissions draw Medicare's attention, how records may move without a separate authorization, and how to refer a patient to Hope Health Network.

What the discharge rule asks hospitals to send

Under 42 CFR 482.43, a hospital identifies early in the stay the patients likely to suffer adverse health consequences after discharge without adequate planning, and gives them a discharge planning evaluation. At discharge, the hospital sends the practitioners responsible for follow-up care the necessary medical information about the patient's current course of illness and treatment, along with post-discharge goals of care and treatment preferences.

Why readmissions matter

The Centers for Medicare and Medicaid Services (CMS) runs the Hospital Readmissions Reduction Program, which lowers Medicare payments to hospitals with more 30-day unplanned readmissions than expected for heart attack, COPD, heart failure, pneumonia, coronary artery bypass surgery, and elective hip or knee replacement. CMS caps the reduction at 3 percent.

Records without a separate authorization

The HIPAA rule at 45 CFR 164.506 lets a hospital share health information with another provider for that provider's treatment of the patient without a separate authorization. When the chart includes records from a federally assisted substance use treatment program, 42 CFR Part 2 also applies, and those records generally need the patient's written consent.

Which practice for which patient

• Needs a primary care provider after the stay, or follow-up for diabetes, hypertension or COPD: Hope Medical Associates provides primary care, including care for diabetes, hypertension and COPD, the Medicare yearly wellness visit, and help establishing a primary care provider after a hospital stay.
• Depression, anxiety or another mental health condition that needs outpatient care: Hope Behavioral Medicine provides psychiatric medication management and counseling for adults with anxiety, depression, ADHD, insomnia, PTSD, OCD, bipolar disorder and postpartum depression, in person in West Ashley and by video.
• An opioid or alcohol use disorder: Hope Addiction Medicine provides medication-assisted treatment for opioid and alcohol use disorders. Treatment typically begins with an in-person assessment, followed by weekly in-person or virtual visits before moving to a monthly schedule, and each plan is tailored to the patient.

You do not need to choose a practice; we route each referral to the right one.

What to fax

A faxed referral should include the patient's name, insurance, the reason for referral and any relevant clinical notes. The information the discharge rule already asks the hospital to assemble for follow-up care is the natural packet to send, so the first visit can build on the stay instead of starting over.

How to refer

The referral line, fax number and secure form are on our referral page, and hospital teams can read more on our hospital transitions page. We typically contact the patient within two business days of a faxed referral, and initial evaluations are often able to be scheduled within a week of the request. If the patient needs to be seen sooner, call us.

Our practices accept Medicare, most major commercial plans, and all South Carolina Medicaid managed care plans except Select Health (First Choice). Self-pay rates are also available.

Our practices are not an emergency service, and the referral form is not monitored for emergencies. For someone in crisis, call or text 988, and in immediate danger, call 911.

This article explains these rules in general terms. It is not legal advice.

Sources: 42 CFR 482.43, condition of participation: discharge planning; CMS, Hospital Readmissions Reduction Program; 45 CFR 164.506, uses and disclosures for treatment, payment and health care operations.

This article is general information, not medical advice, and does not create a patient–provider relationship. Every situation is different, so see a provider who can evaluate yours and develop a plan of care. Any medication discussed here may not be right for you: the right choice depends on your diagnoses, other health conditions and current medicines, so take medication only as directed by the provider managing your care. If you are ever in doubt about an emergency, call 911 or go to the nearest emergency room.