Revised Process for Hospital Discharge Planners

November 14, 2016


Public Act 99-0857 (SB 2929) amends the Hospital Licensing Act to revise the prescreening process for patients discharged to nursing facilities. 

For assessments for skilled nursing services completed in the hospital, PA 99-0857 requires the Care Coordination Unit (CCU) completing the Choices for Care assessment (prescreening) to provide a copy of the assessment directly to the nursing facility to which the patient is being discharged prior to discharge.

  • CCUS are housed in local human service agencies and have contracts with the Illinois Department on Aging as well as Managed Care Organizations.
  • CCUs perform pre-admission screenings of all persons age 60 and older seeking admission to a nursing facility.
  • They also help develop plans of care and link older adults and family caregivers with other agencies that provide that care.

The Act, effective January 1, 2017, reverses the process established in 2014 in which the hospital was required to transmit the prescreening information directly to the nursing facility.

Federal Requirements Remain
The state law does not alter the requirement for completion of any necessary federal Mental Health (MH) or Intellectual/Developmental Disabilities (DD) Pre-Admission Screening and Resident Review (PASRR) Level II assessments and determination prior to nursing facility admission. When these federal MH and DD PASRR requirements are not met, the nursing facility cannot be paid for the person’s care.

Hospitals must continue to notify the CCU of a patient’s pending discharge to a skilled nursing facility at least 24 hours prior to discharge so the CCU can perform the prescreening. It is imperative that the hospital discharge planner communicate with the CCU regarding the selection of the nursing facility after completion of the prescreening so the CCU can send the required documentation to the nursing facility. 

The purpose of the Choices for Care prescreening is to inform the patient and family of all available community services and resources to help prevent premature and/or unnecessary institutionalization.

State Policy Changes
The Illinois Department on Aging will be revising its policy to the CCUs regarding this legislation. The policy provides that when the Choices for Care prescreening assessment is completed in the hospital, the CCU will complete the following forms and transmit them directly to the nursing facility:

  • HFS 2536: This is the Illinois Department of Healthcare and Family Services (HFS) Interagency Certification of Screening Results, and includes the Determination of Need (DON) score.
  • The OBRA Level I screen: This is the Illinois Department of Human Services’ Division of Mental Health, Division of Developmental Disabilities, Division of Rehabilitation Services (DHS-DMH/DDD/DRS) and the Department on Aging’s OBRA Level I Screen.

When the CCU is unable to complete an assessment in a hospital prior to discharge to a nursing facility, the CCU shall notify the Department on Aging (DoA) which shall notify the Department of Healthcare and Family Services (HFS). HFS and DoA shall adopt rules to address these instances to ensure that the patient is able to access nursing facility care, the nursing facility is not penalized for accepting the admission, and the patient’s timely discharge from the hospital is not delayed.