CMS SOM App. X, Tag X-091

Guideline §482.94(c)(ii)

Programs need to ensure discharge planning occurs at an early stage of the patient’s stay to allow

for a thorough assessment of the patient’s needs by each member of the multidisciplinary team,

as well as validation of the patient’s understanding of their responsibilities upon discharge. Each

member of the dedicated multidisciplinary team must be involved in assessing the needs of the

patient in preparation for discharge from the hospital. Areas of assessment for discharge

planning include medical, psychosocial and financial.

The recipient’s medical record must contain documentation that the dedicated multidisciplinary

team participated in the development of the discharge plan to address the individual needs of the

recipient.

Components of a multidisciplinary discharge plan may include, but are not limited to:

• A description of the recommended follow-up appointments and the practitioners expected

to perform the follow-ups (such as the transplant program, a local physician, or both);

• Contact numbers of transplant program staff that can be contacted for questions;

• The clinical signs and symptoms indicative of a potential complication from

transplantation that would necessitate a call to the doctor;

• A transplant recipient/living donor specific nutrition plan, as applicable;

• A plan for addressing psychosocial issues (for example available supports, adaptation to

stress of transplant, etc.);

• Activity restrictions and limitations (for example driving after taking pain medication);

• Need for coordination of other health services (for example physical or occupational

therapies, home care, etc.) and assistance in securing these health services;

• Medication and administration, including the transplant recipient’s schedule for taking

medication and the process to obtain the medication; and

• Any assistance required to access local medical care, equipment or support.