Discharge planning is often a broken link in the chain of care for hospital patients. Older adults and others with complex care needs nearly always need follow-up after they are discharged. They’ll almost certainly have to take new medications. They may need bandages changed after surgery, or physical therapy after a stroke. Unfortunately, they and their families rarely get the information they need to manage once they get home.

That may be changing in important ways. Both states and the federal government are taking steps to require hospitals to improve their discharge plans and better communicate them to patients and their families.

In recent years, many hospitals have done this on their own. Initiatives such as Project RED (readmission discharge), or the Care Transitions Program provide clear, understandable discharge instructions; information about community resources; and involve family caregivers.

The prospect of Medicare penalties for excessive readmissions got the attention of some hospitals. They realized that the days when a hospital stopped caring for, and about, you as soon as you were rolled out the front door had come to an end.

But other facilities have not gotten the message. Now, government is starting to push them more directly to improve discharge planning.

For example, late last year California became the 18th state to enact the Caregiver Advise, Record, Enable (CARE) Act, model legislation that has been pushed by AARP throughout the country. The CARE act requires hospitals to allow a patient to identify a caregiver who would be notified of a pending discharge and be given access to appropriate discharge instructions.

Now, the federal government is cracking down harder. Last November, the Centers for Medicare & Medicaid Services (CMS) proposed detailed new regulations that would govern discharge planning and instructions for hospital and skilled nursing facility patients.

The proposed regulations are complex and extensive, but this is how CMS describes its goal:

“The discharge planning process should ensure that patients and, when applicable, their caregivers, are properly prepared to be active partners and advocates for their healthcare and community support needs upon discharge from the hospital or [post-acute] setting. Yet patients and their caregivers frequently are not meaningfully involved in the discharge planning process and are unable to name their diagnoses; list their medications, their purpose, or the major side effects; cannot explain their follow-up plan of care; or articulate their treatment preferences and goals of care.”

CMS also acknowledges the importance of connecting discharged patients to social supports and services, a critical element of home-based care that is often ignored by the health care system. The proposal puts it this way:

“If the discharge planning team and patients or their caregivers are not aware of the full range of post-hospital services available, including non-medical services and supports, patients may be sent to care settings that are inappropriate, ineffective, or of inadequate quality. The lack of consistent collaboration and teamwork among health care facilities, patients, their families, and relevant community organizations may negatively impact selection of the best type of patient placement, leading to less than ideal patient outcomes and unnecessary re-hospitalizations.”

This is a big deal. If hospitals don’t meet these rules, they won’t be allowed to participate in Medicare or Medicaid. While far-reaching, the proposals are far from perfect.  For instance, they assume that the go-to source for information about community-based services are Area Agencies on Aging (AAAs) and Aging and Disability Resource Centers (ADRCs). These are usually government-funded and run programs.

But AAAs and ADRCs are notoriously variable in quality. Some are excellent. Some are terrible. Some won’t provide information about for-profit providers, a self-imposed limitation that does not serve consumers well. There are other alternatives for information services, including private care managers and private not-for-profits (full disclosure: I am an unpaid board member of one, the Jewish Council for the Aging of Greater Washington). CMS should acknowledge them.

For a more detailed analysis of some other issues in the proposed rules, take a look at this blog post by Anne Montgomery of the Altarum Institute and Leslie Fried of the National Council on Aging.  As Anne and Leslie say, CMS almost got it right, but not quite.

The real story here is one of momentum. High-quality discharge planning,  acknowledging the role of family caregivers and community-based social supports, is an idea whose time has finally come. Hospitals are going to have to get on board. If they don’t, the government is going to make them do discharge planning its way, whether they like it or not.