Caregiver Involvement Crucial to Effective Discharge Planning and Home Care

• Elizabeth Hogue

Caregiver Involvement Crucial to Effective Discharge Planning and Home Care

On May 17, 2013, the Centers for Medicare and Medicaid Services (CMS) issued revisions to the State Operations Manual (SOM), Hospital Appendix A - Interpretive Guidelines for 42 CFR 482.43, Discharge Planning. These interpretive guidelines state that hospital discharge planners/case managers must educate patients' caregivers about what will be required of them after patients are discharged to home. Likewise, revised standards of care published by the Case Management Society of America (CMSA) in 2016 make it clear that case managers/discharge planners are required to involve family members and other caregivers in the discharge planning process.

It often appears to home care providers that patients' caregivers have no idea about what they need to do to assist patients at home. It seems likely that some readmissions may be avoided if caregivers were better able to fulfill their roles at home. Effective preparation of caregivers by discharge planners/case managers may be a factor that makes a difference.

A recent study published in the Journal of the American Geriatrics Society confirms that integrating caregivers into discharge planning processes at hospitals can significantly reduce 90-day readmission rates to hospitals. For this study, researchers conducted a systemic review of previous research designed to assess the effect of caregiver integration into discharge planning processes on healthcare costs. The review included 15 studies involving 4,361 patients.

Analysis of the studies showed that integrating caregivers, such as family members, into the discharge planning process was associated with a 25% reduction in readmissions within 90 days of discharge and a 24% reduction in readmissions within 180 days of discharge.

It also seems likely that home care providers have a role to play in avoiding readmissions. Thus far, activities; such as medication reconciliation, assisting patients to make follow-up appointments with their physicians, education regarding changes in signs and symptoms of their conditions and what to do about them, etc.; seem to make a difference in readmission rates. There is, however, another piece of the puzzle that may make a difference, which has received little attention.

That is, increased support for patients' caregivers may make a difference in the quality of care provided to patients at home. Caregivers have a very "hard row to hoe." Caregiving is physically, emotionally, intellectually, and spiritually demanding. Is it possible that enhanced assistance for caregivers may also impact readmissions to hospitals just as involvement of caregivers in discharge planning processes does?

Now is the time for discharge planners/case managers and home care providers to shine a light on the role of caregivers in the quality of discharge planning and of post-acute care provided to patients.

©2017 Elizabeth E. Hogue, Esq. All rights reserved.

No portion of this material may be reproduced in any form without the advance written permission of the author.


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Elizabeth Hogue,

Owner, Elizabeth E. Hogue, LLC