Hospital Discharge General Guidance and Information
- General LTC admissions: If trying to place patients who are not actively infected with COVID-19 and/or individuals with specialized skilled nursing or other long-term care needs, you should contact facilities within your region to inquire on bed availability and specific patient care capabilities. There are a number of reasons why your preferred long-term care facilities are currently not admitting residents, including a temporary state-imposed or voluntary admissions freeze, and insufficient staffing to safely care for new residents.
The map included in the “Regional Distribution of LTC Facilities” section below is intended to serve as a resource to identify available facilities in your region. - Admissions Freeze: Facilities under a state-imposed temporary admissions freeze. Facilities are subject to such an admissions freeze when certain conditions are met (e.g., >10 new cases in last 7 days, infection control deficiencies, etc.) and DPH has determined an admissions freeze is necessary to protect the health and safety of residents and prevent further COVID-19 transmission. Stopping admissions enables facilities to focus resources such as staff and PPE on the health and safety of their current residents and enables them to stabilize before taking on new residents. An admissions freeze will remain in place until DPH has determined that conditions have improved, and the facility is ready to safely care for new residents. Generally, only 5% of facilities are under an admission freeze at any one time. A list of long-term care facilities with current admissions freeze can be found here. Please check back frequently as this information may change
- COVID-19 positive patients: If trying to place an individual infected with COVID-19 who needs skilled nursing facility level of care, providers should contact facilities regarding acceptance of COVID-19 positive individuals. Some facilities have reported through voluntary survey, that they are accepting COVID-19 positive individuals. A list of these facilities can be found here. This list is update on a monthly basis and therefore the information may have changed.
- MassHealth coverage: For individuals in need of MassHealth coverage, information on the application process can be found here. For further assistance with coverage or eligibility issues, please contact the MassHealth Customer Service Center (800) 841-2900.
Dedicated Nursing Facility Short-Term Rehab Capacity Program
As part of the Commonwealth’s continued effort to address the current hospital capacity constraints and to assist with patient care transitions the Executive Office of Health and Human Services (EOHHS), MassHealth and Department of Public Health (DPH) have implemented a temporary program that adds short-term rehabilitation capacity in all regions of Massachusetts. The goal is to support patient care transitions and reduce the number of patients who are medically ready for hospital discharge but are not able to be transferred due to capacity constraints at SNFs and to help transition them back to the community.
The following Nursing Facilities in each Emergency Medical Service (EMS) region are required to accept all hospital referrals for patients that require short-term rehabilitation skilled nursing services as a requirement of participation in the programs. The facility must be responsive to requests from any hospital for discharge planning and available to accept all new admissions, inclusive of COVID-19 positive patients, from at least 7:00 a.m. to 7:00 p.m., seven days a week. Hospitals should use their usual process to refer patients to the SNFs. In addition, the Nursing Facility must work to ensure individuals admitted under this Program are discharged home into the community, in accordance with the resident’s goals once they are safely able to do so. This includes beginning discharge planning and coordinating with formal and informal community supports as soon as practicable upon admission.
EOHHS is expanding this capacity by adding additional facilities to the short-term rehab capacity initiative over the course of the next month. Please check back frequently as the below list will be updated.
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Regional Distribution of LTC facilities
The map below is intended to serve as a reference and resource to identify facilities within your region. This resource may be used to identify nearby facilities who may specialize in certain patient diagnoses, services or care based on resident needs. The information in this map was sourced through a voluntary survey conducted in April of 2021.
This resource is not reflective of available bed capacity and thus discharge planners should contact the facility for availability or submit referrals through their usual process.
Nursing home consumer information
Information on long-term care options in Massachusetts, individual nursing homes and resident rights among other resources can be found on the Nursing Home Consumer Information webpage. This webpage includes:
- The Nursing Home Survey Performance Tool, a state resource which includes DPH quality scores on an individual facility’s administration, nursing, resident rights, food services, and environmental categories
- Nursing Home Compare, a federal resource from the Centers for Medicare and Medicaid (CMS) that contains detailed information about nursing homes nationwide, including their CMS five-star rating
- Ombudsman Programs, which are advocacy programs available for or on behalf of residents at assisted living facilities, long-term care facilities and those in community care. The ombudsman service offers a way for older adults to voice their complaints and have concerns addressed so they can live with dignity and respect.
In addition, the Commonwealth has created the COVID-19 Family Information Center to provide the latest resources and information for families and loved ones of residents in nursing homes during the COVID-19 pandemic.
EOHHS Long Term Care Discharge Support Line
Discharge support is available to assist staff from acute hospitals and/or other settings such as psychiatric hospitals, who are working with current patients in need of facility-based long-term care (SNF,RH or LTAC) post discharge.
This support line is meant to supplement comprehensive discharge planning efforts as required per applicable DPH, MassHealth and CMS regulations and contracts. Providers and Discharge staff are expected to utilize the resources above before contacting Discharge Support. This service is a resource meant for use by provider staff (discharge and case managers) only. Families and community members who have questions about the care their loved one is receiving during the COVID-19 outbreak should refer to the Long-Term Care COVID-19 Family Information Center.
When to contact Long Term Care Discharge Support:
- Discharge staff should contact the Discharge Support team when they have exhausted the above resources and challenged to find a long-term care placement.
- For MassHealth members enrolled in a MassHealth managed care plan, please contact the member’s managed care plan to coordinate discharge planning prior to contacting the support line. Please see the Accountable Care Partnership Plan (ACPP) Contact List for Discharge Planning for contact information.
How to connect with the Discharge Support Team:
- Please begin with emailing a completed intake form to EHSDischargeSupport@Mass.gov to ensure the support team has all the relevant information.
- Download the intake form: EOHHS Discharge Intake Form To submit a form, you will need to be registered as a user with the secure email system. If you have not used this system before, go to the URL below and register as a new user to send an email via this system: https://ppsecuremail.state.ma.us/encrypt
- You can reach the Discharge Support team by calling (617) 660-4800 or emailing EHSDischargeSupport@Mass.gov. The Discharge Support team is available Monday through Friday, 9 AM to 5 PM.