OAR 333-505-0055: Discharge Planning Requirements

(1) As used in this rule: (a) For purposes of subsection (2)(a) of this rule "lay caregiver" means an individual who, at the request of a patient, agrees to provide aftercare to the patient in the patient’s residence. (b) For purposes of subsection (2)(b) of this rule, "lay caregiver" means: (A) For a patient who is younger than 14 years of age, a parent or legal guardian of the patient; (B) For a patient who is 14 years of age or older, an individual designated by the patient or a parent or legal guardian of the patient to the extent permitted under ORS 109.640 and 109.675. (c) "Mental health treatment" includes treatment for mental health, mental illness, addictive health and addiction disorders. (d) "Peer support" means a peer support specialist, peer wellness specialist, family support specialist or youth support specialist as those terms are defined in ORS 414.025 and who are certified in accordance with OAR chapter 950, division 060. (e) "Publicly available" means posted on the hospital's website and provided to each patient and to the patient's lay caregiver in written form upon admission to the hospital or emergency department and upon discharge from the hospital or release from the emergency department. The written form provided to a patient and lay caregiver may be a summarized version of the policy that is clear and easily understood, for example in the form of a brochure. (2) A hospital shall adopt, maintain and follow written policies on discharge planning and termination of services in accordance with these rules and 42 CFR 482.43. The policies shall include but are not limited to: (a) A plan for continuity of patient care following discharge including: (A) An assessment of the patient’s ability for self-care; (B) An opportunity for the patient to designate a lay caregiver; (C) An opportunity for the patient, and if designated the lay caregiver, to participate in discharge planning; (D) Instructions or training provided to the patient and lay caregiver prior to discharge for the lay caregiver to provide assistance with activities of daily living, medical or nursing tasks such as wound care, administering medications, or the operation of medical equipment, or other assistance relating to the patient’s condition; and (E) A requirement to notify the lay caregiver that the patient is being discharged or transferred; (b) For patients hospitalized for mental health treatment, a plan to: (A) Have a member of the patient's care team encourage the patient to designate a lay caregiver and sign an authorization form for the disclosure of information that is necessary for a lay caregiver to participate in the patient's discharge planning and to provide appropriate support to the patient following discharge as well as an explanation of: (i) The benefits of involving a lay caregiver including participating in the patient's discharge planning in order to provide appropriate support measures; (ii) Only the minimum information necessary will be shared; (iii) The benefits disclosing health information will have on the ability of the patient to see positive outcomes; and (iv) The ability to rescind the authorization at any time; (B) Assess the patient’s risk of suicide with input from the patient’s lay caregiver, if applicable; (C) Assess the long-term needs of the patient which include but are not limited to: (i) Community-based services; (ii) Capacity for self-care; and (iii) To the extent practicable, whether the patient can be properly cared for in the place where the patient resided at time of admission; (D) Develop a process to coordinate the patient’s care and transition the patient to outpatient treatment that includes one or more of the following: community-based providers, peer support, lay caregivers and other individuals who can implement the patient’s care plan; and (E) Schedule a follow-up appointment for no later than seven calendar days after discharge. If a follow-up appointment cannot be scheduled within seven days, the hospital must document why; (c) For a patient actively treated for an opioid use disorder by the hospital and who is being discharged or released to an unlicensed setting or private residence, the provision of at least two doses of an opioid overdose reversal medication and the necessary supplies to administer the medication. The hospital is not required to provide the medication if the patient leaves the hospital against medical advice; and (d) Upon transfer from the emergency department to another hospital, a plan to provide the address of the referral institution to the patient and the patient's family, caregiver, legal representative, or health care representative. (3) Discharge policies developed in accordance with subsections (2)(a) and (b) of this rule: (a) Must be publicly available; (b) Must specify the requirements for documenting who is designated by the patient as the lay caregiver and the details of the discharge plan; (c) May incorporate established evidence-based practices; (d) Must ensure that discharge planning is appropriate to the needs and acuity of the patient and the abilities of the lay caregiver; (e) Must not delay a patient’s discharge or transfer to another facility; and (f) Must not require the disclosure of protected health information without obtaining a patient’s consent as required by state and federal laws. (4) A hospital shall have until December 1, 2018 to comply with subsections (2)(b) and (3)(a) of this rule.