Discharge Planning
Discharge planning is the process of preparing a home health patient to leave agency care safely, whether goals are met, eligibility ends, or care transfers to another setting. It is governed by a Medicare Condition of Participation with specific communication requirements, and it begins at admission, not in the final week of the episode.
What the Conditions of Participation require
The home health discharge planning requirements at 42 CFR 484.58 make discharge planning an ongoing process that starts with the comprehensive assessment and involves the patient, caregiver, and physician. When a patient transfers to another provider, the agency must send necessary medical information to the receiving facility or practitioner, and the clinical record standards set tight timeframes for summaries: a transfer summary within 2 business days of a planned transfer or of becoming aware of an unplanned one, and a discharge summary to the practitioner within 5 business days of discharge. Discharge for cause is separately constrained by the patient rights CoP, which limits the permissible reasons for discharge and requires documented efforts to resolve problems first.
Types of discharge and the notices they trigger
Discharges come in flavors with different obligations. Goal-met discharges are the plan working as intended. Eligibility-based discharges occur when the patient is no longer homebound or no longer has a skilled need. Transfers move the patient to a hospital, SNF, or another agency. When the agency is ending all Medicare-covered services and the patient may disagree, the Notice of Medicare Non-Coverage (NOMNC) must be delivered at least 2 calendar days before services end, preserving the patient's right to a fast appeal through the QIO. A Home Health Change of Care Notice (HHCCN) applies when specific services are reduced or stopped for agency or physician reasons while care continues. A discharge OASIS is required, completed within 2 calendar days of the discharge date or of learning of an unplanned discharge.
Discharge planning and the DTC measure
Discharged to Community (DTC) is a claims-based measure that asks whether the patient was discharged to the community and remained there, without an unplanned hospitalization or death, in the 31 days that follow. It is publicly reported and sits in the claims-based domain that carries 40% of the HHVBP Total Performance Score in CY2026. The measure is effectively a referendum on discharge planning quality: patients discharged with an unreconciled medication list, no scheduled follow-up appointment, and a shaky caregiver plan are the ones who bounce back to the hospital in week two. Timing matters too, since discharging a patient before self-management is established trades a few visit costs for a measure penalty and a readmission.
What good discharge planning looks like
Set the discharge picture at start of care: what the patient will be able to do, who will support them, and roughly when. Then work backward:
- Taper visit frequency so the last weeks rehearse independence rather than extend dependence
- Reconcile the final medication list and confirm the patient has and understands every drug
- Confirm a scheduled follow-up appointment and transportation to it
- Validate caregiver competence with teach-back on remaining care tasks
- Line up community services, equipment, and supply sources before the last visit
- Provide written instructions at an appropriate reading level, including who to call
The final claim should never be waiting on an unsigned order or an incomplete discharge OASIS.
Frequently asked questions
When does the NOMNC have to be given?
At least 2 calendar days before all Medicare-covered services end, whenever the beneficiary may not agree that coverage should stop. It informs the patient of the end date and their right to a fast appeal through the Quality Improvement Organization. Valid delivery, signed or properly documented, is a frequent audit focus.
Can an agency discharge a patient for noncompliance?
Only within the limits of the patient rights CoP. Discharge for cause requires documented efforts to resolve the issues, physician involvement, and advance notice consistent with agency policy. Abrupt discharge of a difficult patient without that trail is a survey citation and potentially an abandonment claim.
Is a discharge OASIS always required?
A discharge assessment is required when the patient discharges alive from agency care, completed within 2 calendar days of the discharge date or of learning of an unplanned discharge. Transfers to an inpatient facility use a transfer OASIS instead, and death at home has its own minimal data collection.