The process of a resident leaving a healthcare facility, known as discharge, is governed by a specific medical authorization called the discharge order. This order marks the formal end of a patient’s stay, whether from a hospital, skilled nursing facility (SNF), or rehabilitation center. A discharge order signifies that the resident no longer meets the criteria for the level of care provided by that institution. While the entire process involves multiple healthcare and administrative professionals, the authority to issue the final medical decision rests with a specific licensed professional.
The Role of the Attending Physician or Licensed Provider
The person who gives the formal order for a resident to be discharged is the attending physician or another authorized licensed practitioner. This individual, often a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO), is ultimately responsible for the patient’s clinical care. The decision to discharge is a medical one, based purely on the resident’s clinical status and the determination of medical necessity.
The physician must document that the resident’s condition has stabilized and that they no longer require the intense level of acute care or skilled services provided by the facility. Depending on state law and facility policy, a licensed independent practitioner such as a Nurse Practitioner (NP) or Physician Assistant (PA) may also be authorized to write the discharge order. The order is entered into the patient’s medical record, often including a final examination note and instructions for continuing care.
This authorization confirms the resident has met their treatment goals and can transition to a lower level of care, such as home, an assisted living facility, or outpatient services. The physician’s determination legally permits the facility to stop billing for the higher level of care, which is important for the institution and the patient’s insurance coverage, especially Medicare. The attending physician is also accountable for coordinating the discharge summary and communicating with the next level of care provider.
Coordination by the Discharge Planning Team
While the attending physician provides the medical order, the practical arrangements for the move are managed by the discharge planning team. This team is typically led by a social worker or a dedicated discharge planner, who manages the logistical steps following the medical decision. Their role is to ensure a safe and smooth transition, not to make the clinical decision about when the resident is medically ready to leave.
The team evaluates the resident’s likely need for post-hospital services, such as home health care, medical equipment, or placement in a Skilled Nursing Facility (SNF). They coordinate follow-up appointments and arrange for necessary services to begin upon the resident’s arrival at the next destination. Federal regulations require this planning evaluation to be conducted by a registered nurse, social worker, or other qualified personnel.
The team provides the resident with information on their post-acute care options, ensuring patient choice is maintained. The final discharge plan, which details all arrangements, must be documented in the resident’s medical record. This coordination helps reduce the risk of a resident being readmitted to the hospital shortly after leaving.
Regulatory Differences Based on Facility Type
The rules surrounding the discharge process, particularly the required notice period, vary between acute care hospitals and long-term care settings like Skilled Nursing Facilities (SNFs). These differences are largely dictated by federal regulations from the Centers for Medicare & Medicaid Services (CMS). In an acute care hospital, discharge planning can move quickly once the resident is medically stable.
Hospitals must provide residents with “An Important Message from Medicare” (IMM) notice near admission and again before discharge, informing them of their rights to an expedited appeal. In contrast, residents in a Skilled Nursing Facility (SNF) have more stringent notification rights regarding a facility-initiated discharge. SNFs must provide at least 30 days’ written notice of a discharge or transfer, unless exceptions apply, such as an urgent medical need or a threat to the safety of others.
This 30-day requirement for SNFs gives the resident and their family time to secure new placement and arrange for a transition. The written notice must clearly state the reason for the discharge, the effective date, and information about the resident’s right to appeal the decision. If the discharge is for a medical reason, the notice must be accompanied by a physician’s order or a medical director’s signature, confirming the medical basis for the transfer.
Patient Rights and the Appeals Process
The medical order for discharge is not final, as residents have the right to challenge the decision, especially in Medicare or Medicaid-funded facilities. If a resident or their representative disagrees with the medical necessity of the discharge, they can file an expedited appeal. This right is guaranteed under federal law and protects residents who feel they are being discharged too soon.
The appeal is reviewed by an independent third party known as a Quality Improvement Organization (QIO). The QIO is contracted by Medicare to review the medical necessity of the continued stay. The resident must contact the QIO no later than their planned discharge date to initiate the review.
Once the appeal is filed, the resident is permitted to remain in the facility while the QIO reviews the case, and Medicare will continue to cover the services during this period. The burden of proof falls on the facility or the Medicare Advantage plan to demonstrate to the QIO that the discharge is medically appropriate. If the QIO sides with the resident, the facility must continue providing care; if the QIO upholds the discharge, the resident’s coverage ends shortly thereafter.