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December 22, 2015

Centers for Medicare & Medicaid Services
Department of Health and Human Services

Attention: CMS–3317–P

The National Committee for Quality Assurance (NCQA) would like to thank the Center for Medicare and Medicaid Services (CMS) for the opportunity to comment on the Notice of Proposed Rulemaking to revise discharge planning requirements for hospitals and home health agencies. We applaud the effort to improve quality and experience by modernizing the way facilities engage and support patients through the discharge planning process.

Outcomes improve when providers engage patients about what matters most to them. Discharge planning should explicitly document those conversations and implement goal-oriented care according to the patient’s treatment preferences. This will empower patients and their caregivers to be active participants in their own care, helping to ensure better adherence to treatment plans that meet both medical and non-medical needs. Facilities should also ensure those goals and preferences are communicated across providers and settings. Studies show comprehensive discharge care plans promote use of primary care, which helps control recurrent readmissions and reduce downstream costs.

Discharge planning can be further improved by notifying patients’ health plans and primary care physicians of the hospitalization. This enhanced communication helps reduce redundant services. It’s also important that the facility coordinate with any other case management services and providers the patient may use, including health plan case management and long-term services and supports (LTSS) case management. These considerations will also better prepare patients to engage community-based providers and services that can supplement their post-discharge needs. Leveraging these additional services can help address the behavioral and socioeconomic determinants of health and contribute to improved outcomes.

The proposal requiring discharging facilities to use and share quality and resource use data is particularly encouraging. Giving consumers access to such data increases transparency and allows them to select high-quality post-acute care providers. It also allows CMS, health plans and other stakeholders to determine which providers are implementing value-based, patient-centered practices and producing meaningful quality improvement.

We also believe CMS should be aware that although many of these policies are routine practice in many facilities, this change could potentially incentivize hospitals and post-acute care settings to create their own post-discharge programs without actually coordinating with outpatient providers. That coordination across settings is not only an integral part of ensuring that patient needs are met, it helps to reduce avoidable complications, adverse events and hospital readmissions.

Thank you again for the opportunity to comment on the proposed rule. Please contact Joe Castiglione, Federal Affairs, at or 202-955-1725 if you have any questions.



Margaret E. O’Kane