SNFs should ensure that residents and their homes are adequately prepared prior to discharge not only because it could reduce the risk of rehospitalization, but also because the MDS 3.0 draws attention to this aspect of discharge planning.
The MDS 3.0 contains two new items related to discharge planning: Q0500, Return to Community, and Q0600, Referral. These items are intended to support a resident’s expressed interest to return to the community and ensure collaboration between the SNF and the local contact agency to facilitate this transition.
Certain answers to Section Q items will trigger the need for a discharge planning evaluation, which will be done by a local contact agency in collaboration with the facility. The need for a discharge planning evaluation is triggered when:
- The resident or family wants to speak to someone about return to the community (Q0500B = 1) and
- There is no discharge plan in place for the resident to return to the community (Q0400A = 0) and
- A determination was made that discharge to the community was feasible (Q0400B = 1)
In addition to the new items related to discharge planning, the MDS 3.0 requires facilities to complete a discharge assessment. Although the discharge assessment required under the MDS 3.0 means more work for the interdisciplinary team, it could help improve care transitions and even the quality of care people receive.