By Shara Ragan, LMSW, Clinical Executive at Aidin
A hospital stay can hold frightening, even life-changing moments, and the conversation about what comes next is rarely the loudest one. But it’s a very important one, and case managers guide it.
When it goes well, a patient leaves feeling confident in where they’re headed and why. That’s the work most of us got into this profession to do. Patient choice sits at the heart of that moment. It's not just a regulatory requirement; it's a patient's right, and honoring it well is one of the most powerful ways we advocate for the people in our care. It's also core to who we are as a profession: CMSA's Standards of Professional Case Management Practice call on us to facilitate client self-determination through "advocacy, shared and informed decision-making, counseling, and health education."
When patient choice becomes a form
Ask a room full of case managers what "patient choice" looks like at their hospital, and too often the honest answer is: a form. A list of post-acute providers, frequently pulled straight from the Medicare website, handed to the patient somewhere near discharge, signed, scanned, done.
A list of names can’t tell a family whether a provider can meet the patient’s clinical needs, is in network, or has availability. So the burden shifts to the family: time spent researching and touring facilities without the information to know whether any of it is a real option.
The encouraging news? Rebuilding the process starts with what case managers already do best: turning that piece of paper into an informed decision, supported by a knowledgeable guide at the patient's side. The right technology can make that easier, but the best practices shared below work no matter what tools you have.
A conversation, not a form: what CMS really requires
I spent years in hospital case management before moving into a role where I now work with care management teams across the country, and I’ve seen this from both sides. The checkbox version of patient choice doesn’t just shortchange patients; it creates risk for the hospital. Patients who land in the wrong setting are more likely to be readmitted, which affects both the patient and the hospital’s reimbursement. Referrals bounce back as denied because nobody verified network status or capabilities up front, creating more work for a care manager who is already stretched. And when a surveyor asks for proof that meaningful choice was offered, a signature on a generic list is a thin defense.
It's worth remembering what CMS actually asks of us. The discharge planning requirements don't say "hand the patient a list." The 2019 discharge planning final rule requires hospitals to involve patients in discharge planning, honor their goals and preferences, and give them access to quality and resource-use data about post-acute providers so they can make an informed decision about their next level of care.
That’s a conversation, not a form. And needing post-acute care, even in-home care, is new and frightening for most patients. The good news is that any care management team can achieve a meaningful patient choice process, regardless of organization size, resources, or your tech stack. Here are five practices that help make the patient choice process both compliant and workable.
1. Build a choice list that’s actually usable
A meaningful choice list (that’s the phrase I always come back to) is more than a name on a piece of paper. It carries everything a patient needs to make an informed decision: what services and capabilities the provider offers, whether they’re in the patient’s network, whether they have availability, and publicly available quality information.
Getting there starts with the source. Pull provider information directly from the Medicare website, and for managed care and commercial patients, check payer websites routinely. There’s no point handing a patient a blanket list of facilities that aren’t in their network. One caution from the field: payer directories aren’t always kept up to date, so verify rather than assume.
Then give the list an owner. Before implementing any new technology, my department kept a shared drive with lists for each level of care that everyone could access. Maintaining it can be a shared effort, but one person needs to own it, whether that’s the department manager or director, or someone they designate. Ownership creates checks and balances, and it’s how you avoid quietly handing patients outdated information. Refresh the list at least every six months or as soon as you’re made aware of a change.
Finally, tailor it. The most common mistake I see isn’t an inaccurate list — it’s a generic one. A patient may want a facility close to their daughter’s home rather than their own. You only learn that by asking. Which brings us to timing.
2. Start the conversation on day one and document as you go
Discharge planning starts at admission. It’s a multidisciplinary effort, but the case manager’s initial assessment is where the choice conversation begins, even before anyone knows what the post-acute need will be. Meet the patient where they are and ask:
- What are your goals?
- What’s most important to you?
- What will it take to get you home safely? Have you ever been to rehab before, and are you familiar with any facilities?
Once the care team identifies the level of care, go back for the more detailed conversation: Do you have any preferences when it comes to facilities?
Then document things in real time. Whether that’s in the patient’s room, right after the meeting, or after a few visits, what matters is that documentation happens promptly and captures the essentials: when the choice list was given, who it was provided to, and for what level of care. Some surveyors will ask to see the actual list that was provided. Some will ask the patient directly: were you given a list, did the hospital influence your choice, did the options reflect your preferences?
Waiting until the end of the day is where things break down. You forget critical pieces of the conversation. Your note is timestamped hours after the meeting actually happened. And because discharge planning is multidisciplinary, any delay becomes everyone’s delay: if PT or OT doesn’t document their recommendation until the end of day, I may not see it until the next morning — and I can’t start the referral process until I do. One late note can stall a patient’s entire transition.
3. Keep the process free of steering
Non-steering is one of the most scrutinized parts of the discharge planning rules, and it’s also where well-meaning case managers get tangled up. Patients ask all the time: “If this were your family member, where would you send them?”
We're trained never to steer patient choice. However, we don’t want to take that to the extreme and respond, "It's your decision, I can't help you." This is more common than we'd like to admit: in a Health Affairs study of 98 patients discharged to skilled nursing facilities, only four reported receiving any information about facility quality, largely because staff believed patient choice rules prohibited sharing it. That's not neutrality; that's abandonment. You still have to help the patient make an informed decision.
The line I’ve found that works is honest and simple: “I can’t choose for you, but I can help you compare.” Walk them through objective, public information such as Medicare star ratings and other quality data. Encourage them to tour facilities and ask friends and community members what they know. And tailor the comparison to what matters to each patient: if I were picking for my own mother, her needs and preferences wouldn’t be the same as this patient’s, and it helps to say that out loud.
Guiding them through the data isn’t steering. It’s the job.
4. Build in provider accountability through the patient’s eyes
A choice list is only as good as the availability behind it. When a chosen provider goes quiet as discharge approaches, the patient's choice is no longer real. Repeated unanswered attempts tell me that the provider is no longer available, and the patient needs to move on.
How quickly you make that call depends on how close the patient is to discharge. But the conversation with the patient should be honest: “We’ve made several attempts to reach them, and we don’t want to delay your discharge. Do you have another preference?” That’s why it’s smart to have patients identify a second choice up front: “You chose ABC Home Health as your first choice. Can you identify a second choice in case they don’t respond or can’t meet your needs?”
Two important boundaries here:
- CMS does not allow you to remove providers from the choice list, even those with a documented pattern of unresponsiveness, so managing patient expectations is your real lever.
- Honoring patient choice does not mean waiting indefinitely on a provider who can’t confirm.
Keep the focus where it belongs: not on building scorecards, but on whether the list the patient is looking at still reflects reality.
5. Make compliance part of the workflow, not an add-on
The first four practices only stick if they live inside the daily routine, not alongside it. That means choice conversations from the start of the stay, the patient actively involved throughout, and alignment with the patient’s goals at every step. The process should feel like the patient’s decision because it is.
For leaders, the discipline is auditing and presence. Most hospitals have daily multidisciplinary rounds, and a good leader also routinely reviews charts or runs reports to confirm that patient choice is not only provided but documented. There's no substitute for seeing the process where it actually happens; walking the floor tells you things a report never will.
If you don’t have reports built, start with a random selection of cases and review the charts directly. Longer term, structure matters: documentation captured only as narrative text can’t be extracted into a report. Capturing choice in a flow sheet or another centralized, structured spot in the EMR is what makes ongoing auditing feasible instead of heroic.
What should you measure? Not just whether choice was given, but the quality of it, including:
- Your compliance rate
- The percentage of referrals offered to more than one provider
- How timely the patient received the list and whether it allowed enough time to make an informed decision
- Whether the referrals that went out actually aligned with the preference the patient stated
And when you find your high performers — recognize them.
The bigger why
It’s easy to talk about patient choice in the language of audits, and audit-readiness matters. But the real measure of this work was never whether we checked the box on patient choice. It’s whether we honored the patient’s voice.
Patient choice done well isn’t a form or a list. It’s a conversation, a decision, and a right. Our patients are stepping into a phase of care they may not have navigated before, and sometimes they're scared. We’re their guide through that. It’s easy to get caught up and lost in the paperwork. However, the paperwork was always just the record of something more important: helping a patient claim a voice and giving them a real say in what happens next in their own care.
Bio: Shara Ragan is a Clinical Executive at Aidin, partnering with hospital and health system leaders to strengthen discharge processes and post-acute placement, aligning clinical needs with the right providers. She spent 16 years at AdventHealth Kansas City, beginning as a floor social worker and rising to Director of Care Management, where she led a 40+ person team and helped launch the Post-Acute Care Collaborative and General Inpatient Hospice program. She has a proven track record of designing care coordination strategies that shorten length of stay, reduce readmissions, and improve patient transitions — all while keeping team morale high.
References:
Case Management Society of America. (2022). CMSA standards of professional case management practice (Rev. ed.). https://cmsatoday.com/2025/09/29/cmsa-standard-of-professional-case-management-practice/
Centers for Medicare & Medicaid Services. (2019, September 26). CMS’ discharge planning rule supports interoperability and patient preferences [Press release]. https://www.cms.gov/newsroom/press-releases/cms-discharge-planning-rule-supports-interoperability-patient-preferences
Tyler, D. A., Gadbois, E. A., McHugh, J. P., Shield, R. R., Winblad, U., & Mor, V. (2017). Patients are not given quality-of-care data about skilled nursing facilities when discharged from hospitals. Health Affairs, 36(8), 1385-1391. https://doi.org/10.1377/hlthaff.2017.0155