Hospital discharge planning under 42 CFR 482.43 is a process focused on patients' goals and treatment preferences, with patients and caregivers or support persons as active partners in planning post-discharge care. Integral Healthcare Solutions (IHS) drafts policies, evaluations, provider-list procedures, handoff templates, transfer policies and review tools for hospital clinical leaders to approve. IHS is a consulting firm, not a law firm.
Last updated: November 2026
What does 42 CFR 482.43 require of a hospital?
The process and the discharge plan must be consistent with the patient's goals for care and treatment preferences, ensure an effective transition from hospital to post-discharge care, and reduce the factors leading to preventable hospital readmissions.
Edition: this page follows the eCFR text in the govinfo bulk data for Title 42 (file built November 4, 2026; title last amended October 8, 2026), page opened November 5, 2026. The section's last amendment in that edition is 89 FR 94592, November 27, 2024. Read the current text at 42 CFR 482.43 before you rely on this page.
Requirements by paragraph
| Paragraph | Requirement |
|---|---|
| Opening text | An effective process focused on the patient's goals and treatment preferences, with the patient and caregivers or support persons as active partners. |
| (a) Early identification | Identify, at an early stage of hospitalization, patients likely to suffer adverse health consequences upon discharge without adequate discharge planning, and evaluate them and any other patient on the request of the patient, the patient's representative or the patient's physician. |
| (a)(1) to (a)(4) The evaluation | Evaluate promptly enough to arrange appropriate post-hospital care before discharge and avoid unnecessary discharge delays. Assess likely need for appropriate services, including but not limited to hospice, extended care, home health, non-health care services and community-based care providers, plus availability and patient access. Include the evaluation in the patient's medical record for use in establishing an appropriate discharge plan, and discuss its results with the patient or representative. At the patient's physician's request, arrange plan development and initial implementation. |
| (a)(5) Who develops it | Any evaluation or plan required by paragraph (a) must be developed by, or under the supervision of, a registered nurse, social worker or other appropriately qualified personnel. |
| (a)(6) Re-evaluation | Regularly re-evaluate the patient's condition to identify changes requiring plan modification; update the plan as needed to reflect those changes. |
| (a)(7) Reviewing the process | Regularly assess the process, including ongoing, periodic review of a representative sample of plans, including patients readmitted within 30 days of a previous admission, to ensure plans respond to post-discharge needs. |
| (a)(8) Post-acute data | Assist patients, families or representatives in choosing post-acute providers using and sharing data including, but not limited to, home health agency, skilled nursing facility, inpatient rehabilitation facility or long-term care hospital quality and resource use measures. Ensure the data are relevant and applicable to the patient's care goals and treatment preferences. |
| (b) Discharge and handoff | At discharge, discharge the patient and, where applicable, transfer or refer the patient with all necessary information about the current course of illness and treatment, post-discharge care goals and treatment preferences, to the appropriate post-acute providers, suppliers, facilities, agencies and other outpatient providers and practitioners responsible for follow-up or ancillary care. |
| (c) Transfer protocols | Effective July 1, 2025, maintain written policies and procedures for transferring patients under hospital care, including inpatients, to the appropriate care level, including another hospital, as needed to meet the patient's needs. Provide relevant staff annual training on those policies and procedures. |
| (d)(1) Provider list | For home discharges referred for home health, transfers to skilled nursing facilities for post-hospital extended care, or transfers to inpatient rehabilitation facilities or long-term care hospitals for specialized hospital services, paragraph (d) adds to (a) and (b). Include available Medicare-participating providers in the discharge plan: home health agencies serving the patient's residence within their agency-defined areas, or facilities in the patient's requested area. Home health agencies must request listing. Present the list only when the evaluation finds those services indicated and appropriate; document presentation to the patient or representative in the medical record. Tell managed-care patients to verify network participation with their organization; share network information with the patient or representative if the hospital has it. |
| (d)(2) Patient choice | Inform patients or representatives of freedom to choose participating Medicare post-discharge providers and suppliers. When possible, respect their care goals, treatment preferences and other expressed preferences. Do not specify or otherwise limit available qualified providers or suppliers. |
| (d)(3) Financial interest | In the discharge plan, identify referred home health agencies or skilled nursing facilities in which the hospital has a disclosable financial interest as specified by the Secretary, and any home health agency or skilled nursing facility with a disclosable financial interest in a hospital under Medicare. Disclosability is determined under 42 CFR Part 420, Subpart C. |
IHS maps requirements to documents and evidence; the regulation does not prescribe a separate document for every paragraph.
Who needs it and what triggers it?
Hospitals subject to 42 CFR 482.43 need a discharge planning process. IHS identifies the following project triggers as of November 5, 2026; they are not additional regulatory deadlines.
- A provider list or data-sharing procedure not updated to paragraphs (a)(8) and (d).
- No written transfer policy or no record of annual training under paragraph (c).
- No documented review of a sample of discharge plans, or a sample that leaves out patients readmitted within 30 days, under paragraph (a)(7).
- Separate handoff forms for each referral type, where the hospital wants one template that meets paragraph (b).
How IHS helps
IHS runs a gap assessment of the hospital's process against each paragraph of 42 CFR 482.43, maps the evidence the hospital already has to each paragraph, drafts what is missing, runs a mock record review and supports readiness. Thomas G. Goddard, JD, PhD, IHS founder and former URAC Chief Operating Officer and General Counsel, leads the work. This build sits in Program Development, alongside compliance program development and Compliance Services.
IHS drafts handouts and annual-training outlines.
What you supply
You supply clinical leader approval of every document, the post-acute quality and resource use data you will share, your provider list contents, staff training delivery, and counsel's review of the financial interest disclosure wording.
The real limit
The hospital implements the process through appropriately qualified personnel. IHS does not evaluate patients or choose discharge destinations, does not decide clinical content, does not guarantee a survey result, and does not contact CMS or any other authority for the hospital.
What to have ready
IHS requests these preparation materials, mapped to 42 CFR 482.43, current eCFR text opened November 5, 2026; this is not a list of separately mandated forms.
- Current policy and approval date (42 CFR 482.43 opening text).
- Early-identification method (42 CFR 482.43 (a)).
- Evaluation form and sample record entries (42 CFR 482.43 (a)(1)–(4)).
- Evaluator/planner qualifications and patient re-evaluation triggers (42 CFR 482.43 (a)(5)–(6)).
- Plan-review sample, including readmissions within 30 days of a previous admission (42 CFR 482.43 (a)(7)).
- Quality and resource use data shared with patients (42 CFR 482.43 (a)(8)).
- Handoff forms (42 CFR 482.43 (b)).
- Transfer policies, procedures and annual-training evidence (42 CFR 482.43 (c)).
- Provider lists, HHA listing requests, managed-care network procedure and presentation records (42 CFR 482.43 (d)(1)).
- Patient-choice wording (42 CFR 482.43 (d)(2)).
- Disclosable financial-interest information for the discharge plan (42 CFR 482.43 (d)(3)).
The free introductory call is where IHS walks through the list with you.
How it compares
A hospital can build in house or use outside drafting support; IHS does not rank them.
| Path or program | What it involves | Note |
|---|---|---|
| In-house build by case management or nursing leadership | Staff write all the documents. | Hospital staff perform the drafting. |
| Outside drafting support (the IHS model) | IHS drafts; the hospital supplies data and decisions. | Clinical leaders still approve and own the process. |
| Hospital QAPI program | 42 CFR 482.21 governs QAPI separately (current eCFR, page opened November 5, 2026). In IHS's reading as of that date, discharge-plan review can inform QAPI; it does not replace either condition. | See hospital QAPI program build. |
The hospital stays accountable on every path. See swing-bed program readiness.
What it costs
42 CFR 482.43 is a federal condition of participation, and the text carries no application fee or other authority fee.
The cost of a build depends on how much of the policy, forms and review tool already exist and the referral types and units covered. IHS scopes each engagement after a free introductory call.
What this is not
- IHS is a consulting firm, not a law firm; it provides no legal advice or guarantee of a survey outcome. The hospital's counsel advises on legal questions.
- IHS does not contact, submit to or correspond with CMS or any state agency. The hospital holds its own records and answers for them.
- This page covers 42 CFR 482.43 for hospitals under Part 482, not critical access hospitals, state discharge laws or accreditor standards.
Frequently asked questions
What is hospital discharge planning under the Conditions of Participation?
Under 42 CFR 482.43, hospitals must have an effective discharge planning process focused on patients' goals and treatment preferences. Patients and caregivers or support persons participate actively in planning post-discharge care.
Who must receive a discharge planning evaluation?
Paragraph (a) requires early identification and evaluation of patients likely to suffer adverse health consequences after discharge without adequate planning. Other patients must also receive an evaluation when requested by the patient, representative or patient's physician.
Who develops the discharge plan?
Paragraph (a)(5) covers every evaluation or plan required by paragraph (a). A registered nurse, social worker or other appropriately qualified personnel must develop it or supervise its development.
What must the post-acute provider list include and when is it presented?
Paragraph (d)(1) requires available Medicare-participating home health agencies serving the patient's residence within agency-defined areas, or skilled nursing facilities, inpatient rehabilitation facilities or long-term care hospitals in the patient's requested area. Home health agencies must request listing. Present the list only when the evaluation finds those services indicated and appropriate, and document presentation to the patient or representative in the medical record. For managed-care patients, explain the need to verify network participation with their organization and share network information if the hospital has it.
Can the hospital steer patients to a provider?
Paragraph (d)(2) prohibits specifying or otherwise limiting available qualified providers or suppliers and requires notice of freedom to choose participating Medicare post-discharge providers and suppliers. When possible, the hospital must respect the patient's or representative's care goals, treatment preferences and other expressed preferences.
What changed on July 1, 2025?
Effective July 1, 2025, paragraph (c) requires written policies and procedures for transferring patients under hospital care, including inpatients, to the appropriate care level, including another hospital, as needed to meet patient needs. Relevant staff must receive annual training on those policies and procedures.
How must the hospital review its own discharge plans?
Paragraph (a)(7) requires regular assessment of discharge planning. That includes ongoing, periodic review of a representative plan sample, including patients readmitted within 30 days of a previous admission, to ensure plans respond to post-discharge needs.
What data must the hospital share when patients choose a post-acute provider?
Paragraph (a)(8) requires assistance with post-acute provider selection using and sharing data including, but not limited to, home health agency, skilled nursing facility, inpatient rehabilitation facility or long-term care hospital quality and resource use measures. The hospital must ensure the data are relevant and applicable to the patient's care goals and treatment preferences.
What does IHS draft and what do clinical leaders approve?
IHS drafts the policy, forms, procedures, transfer policy, training outline and review tool. Clinical leaders approve every document and supply the data, list contents and training. Counsel reviews the disclosure wording.
Does IHS contact CMS for the hospital?
No. IHS does not contact, submit to or correspond with CMS or any state agency. The hospital holds its own records and answers any review of them.