00:00:01:27 - 00:01:18:14
Adam Delmolino
Okay. Good afternoon and welcome. My name is Adam Delmolino, and I am the senior Director of Virtual Care and Clinical affairs here at the Massachusetts Health and Hospital Association. Thank you so much for joining us for today's call with regarding a refresher with regard to the discharge planning processes, both for discharges for patients who are homeless or housing unstable in the MassHealth program and also a general overview of, the EHS discharge support program and our, our good friend Marylouise Gamache. I’d like to offer the opportunity, if just and inform and let everybody know that we will be recording this presentation for review at a later date. So if you have colleagues who are unable to join us on today's call, we'd be happy to share that with them.
We'd also ask folks to stay on mute throughout the presentation, if possible. And if you do have questions, please enter them into the chat and we will take the questions at the conclusion of today's call, actually after each of the presenters, I think more likely. If anybody else has any questions or concerns, seeing none, then I would like to introduce Emily Cooper from MassHealth and the Executive Office of Aging and Independence for a brief overview of today's presentation. Emily, take it away and thanks so much for joining.
00:01:18:17 - 00:33:05:17
Emily Cooper
And thanks, Adam, and thanks for having us and for recognizing Elder Affair's new name of Aging and Independence. So, I am Emily Cooper, and today I'm wearing my MassHealth hat, and I oversee, I'm the Director of the Housing, Homelessness, and Health Care Policy team at MassHealth.
Some of you may not have even known that we had a housing team at MassHealth. We are small but mighty and we work across all of MassHealth to think about policies and to oversee programs related to people experiencing homelessness or at risk of homelessness or experiencing housing instability. You may have seen me in other venues, and I want to apologize first. I've got two screens going, but a camera on one, and I just apologize if I'm looking in the wrong direction.
What I'm going to review today is some guidance that's been in place for a few years that has been, I think, useful in sort of laying out the parameters of who is responsible for doing what when you have a person who is in a hospital, that has been admitted and they need to go someplace and they're experiencing homelessness or housing instability.
I'm going to talk to you a little bit about what the requirements are that MassHealth has put in place. But we also want to talk about what the resources are that are online, but also Marylouise is going to talk about how, you know, these are tricky situations. Lots of different situations come up and Marylouise is really your go-to problem solver to work with you to figure out, how to deal with some of the hard discharges. So, thank you everybody for joining today and for inviting us to do this. I am going to walk through a little bit of a presentation. There are a whole bunch of attachments, attached to the meeting maker that Adam sent out I'm going to reference all of those. You don't need to look at them right the second, but just make sure that, when you later say, gosh I don't have that PowerPoint, it's right there.
So the first thing I'm going to do, if I can figure out how is to share my screen, because I want to start with the resources. So we have a whole website, and we spent a fair amount of time, this was an interagency effort between MassHealth, EOHHS with Marylouise, the Executive Office of Housing and Livable Communities that oversees shelters, and the Department of Mental Health, to align on the messaging we were giving out regarding people who were hospitalized and ready for discharge and they were homeless or housing unstable. And so we do have a website here with a lot of information. It doesn't look like it because it's all hidden. But I want to just click on here. There are different tools. The resources I'm going to talk about today are in the agency targeted resources. There is a specific training that you can take and even get credit for, and I get a little note saying you've taken the training and the certification at the end, of how to think about discharge planning for this population. There is an online tool here. People often said, what do we do? You know, every situation is different. And so we actually created a choose-your-own-adventure tool, for lack of a better word, where you put it in, I hope you can see me walking through this, you'd put it in sort of what is the patient able to care for themselves independently, and you would say yes or no, and then it would take you to the next question and it would tell you what you should do.
So we have spent a fair amount of time, I'm just going to go backwards, sorry, coming up with resources here. So please spend the time and take a look at them. You'll see when you call me or you call Marylouise, we will direct you back here. Just to spend a moment on the EOHHS agency targeted resources, I'm going to spend a lot of time talking about these MassHealth bulletins, which are still in effect, and about the frequently asked questions. Here is also where you can find information about DMH or DDS. Mass Rehab Commission, which needs to be updated to MassAbility, things like that. People in need of MassHealth coverage. So, lots of information here, including we have information for shelter providers. So we direct them as well. And then you have EHS discharge support where we're going to talk to Marylouise and she is going to walk through that walk you through that in a little bit. So please, spend some time after this and see what's up there. And now I'm actually going to turn to the PowerPoint. And first question you're going to ask me is, can we get a copy? So, Adam, I think he already put the copy in the meeting maker and maybe even, sent it out to you so you're ahead of the game.
So we're going to spend a little bit of time going through what we're talking about when we're talking about discharge planning and people experiencing homelessness. If I can get this to move. There we go. We went through the resources. And this is also, again, other things that are there. The shelter contacts are there, things like that. So what are the MassHealth requirements? So we do have three MassHealth bulletins. And these bulletins, I'm going to try and make this a little bit easier for you to read, here we go. These bulletins, there's one for Psychiatric Inpatient Hospitals, there's one for Acute Inpatient Hospitals, and there's one for Managed Care Entities.
And the two for the hospitals are very similar. The Managed Care Entities also, they're designed to mirror each other, and they were issued as a package. And it is focused specifically on MassHealth members who are homeless or housing unstable prior to admission or discharge. And I want to clarify; we're really looking at inpatient admissions. We're not talking about people who went into the emergency room and then left from the emergency room. We're talking about people who have been inpatient in a psychiatric or acute inpatient hospital. And I didn't call them out earlier, but I know on the on the call today, we have a lot of MassHealth folks, on the call who are listening in, who work with those hospitals, we also have a lot of DMH folks, so everybody has been aligned and is in aware of this presentation and the information that I'm giving out. This information and these bulletins have been incorporated into the contracts, or we call them RFAs with the hospitals and the contracts with the Managed Care Entities as well.
The goal is really not to solve every situation; the goal is to not do it alone. So what we found was that the discharge planner was often calling every shelter in town or calling every, or trying to find the managed care person, couldn't find a managed care, really beating the bushes, trying to find some place for someone to go who's ready for discharge we know your beds are full, your emergency room is full. There's a lot of pressure to get that person out. But you were doing it often, sort of like, oh, well, I have these notes that my predecessor gave me about where to call. What we really wanted you to do was to bring in everybody who touches that individual. So that might be a Managed Care Entity, and today it might be a MassHealth Community Partner. It might be Department of Mental Health or, Department of Developmental Services. It might be other case managers. It might be the shelter provider where the shelter they came from, to both learn more about that individual and what resources might be available to them, to learn what resources those agencies might have access to that you don't, and to work together to brainstorm, because, you know, I know somebody right now. I can't see your faces because I can only see the PowerPoint. Somebody is shaking their head saying, I've called the shelter they were no help or the managed care people never get back to me. And we really tried to address those things. We literally have called and you'll see this later, we have had the state tell the shelters, you can't just say, oh, you're a hospital, I don't want to talk to you. You actually need to lean in and have a protocol for how you address calls coming from hospitals and how you work together. So there are requirements on them to work with you. We actually even came up with there is a special phone number, or contact number, sorry, it's not always a phone, it can be an email for each MassHealth Managed Care Entity that's available between 8 a.m. and 6 p.m. every day of the week, just for your discharges of people experiencing homelessness, because I heard too many times that you called the one-800 number and never heard back. So we got you a special contact person. So we're going to go through some of that now.
All right. So I want to just flag for those of you who are also licensed by DMH, in addition to the MassHealth requirements I'm going to go over, DMH which has regulations about discharge planning as well, which I have put here, which is a facility shall make every effort to avoid discharge to a shelter or street. That means you have to take steps to identify alternatives. So it's not just MassHealth, but DMH as well has has these requirements in place. They actually have you submitting regular reports. You have to keep a record and you also have to submit information to them. I want to also flag in the middle here, it talks about in the case of a competent refusal, if the person does not want to be discharged wherever it is that you're working with them on. All of underlying all the information I'm talking about today is this understanding that we know that some people don't want to talk to you, don't want to be involved in discharge planning or just walk out, right, or just go, I'm going to the shelter. You're not held accountable for that. We're only asking you to do what you can do when the member is also willing to meet you part way. So we recognize I know somebody is going to say, well, we have people who don't want to talk to us. I totally get that.
So what these bulletins say, and I'm going to go through a little bit, is one, as soon as the person is admitted to the hospital, within 24 hours, you need to be talking about their housing situation. Is that a situation that is, you know, something that they need to think about oh gosh, while I'm here, I need to get my rent paid. And if I don't, I'm going to lose my housing. Or is it, gosh, I know this person is experiencing homelessness, we're going to have to deal with this at some point in the future because they have nowhere to go back to. So we want to make sure that you're looking at it within 24 hours. And technically, all of all of the regulations, not just for people experiencing homelessness, but all discharge planning activities have to start within three days of admission, three working days.
We require that you invite and encourage everybody, anybody in that discharge planning. So the member, their family members, their guardians, their primary care providers, their behavioral health providers, community partners, case managers for anybody who's affiliated with DMH, DDS, oh, and I got it right this time, MYB, which is the new acronym for Mass Rehab Commission, it is MassAbility. You know what I think it is MBY, so I didn't get it right. For anybody who's already affiliated with DMH, DDS, or MBY, you're supposed to be reaching out to their case manager to make sure they are participating in the discharge planning as well. If you're not sure who that is, we can help you and I will give you contact information for how to get connected with those folks.
What else needs to happen? Well, for those folks who are not affiliated with DMH, DDS, or MassAbility, within two days of their admission, if you think they could benefit from those services, you need to help them submit an application. And in the bulletin, we talk about how you can apply for to receive those services. For those of you that are DMH licensed facilities, there's actually a DMH liaison for every facility/unit. And we can get you that information. If you're having problems with DMH applications, for example. But there is a requirement that within two days of admission, if the person might be eligible for those services, you're helping them apply for them. I know that is a big lift, so I just want to make sure that that's called out. If somebody has a substance use disorder, you can call the DPH hotline and talk to them about what treatment services and options might be available.
One of the things I hear over and over and over again when I find out about discharges that may not have gone exactly as planned, is that the managed care plan, which we call Managed Care Entity or MCE at MassHealth, was unaware. Now unaware, you're going to say, well, they have patient ping or they pay for this day, so they know. I sent them something in the portal or we have talked on our EHR, and they should look there. But even though they even though they got all those things, they were not really involved, the right person did not get the information about this discharge and so they weren't able to talk to you and weren't able to say, oh, hey, I have a contract with this housing search provider, let's get them involved and see if they can help, for example. So we have required every Managed Care Entity to designate an individual point of contact for their hospitals and they are supposed to disseminate that information to you all.
That point of contact needs to be accessible, as I said, 8 a.m. to 6 p.m. each day of the week, including weekends. They're supposed to respond within 12 hours of hearing from you, and they're not allowed to use a regular customer service line. This is a separate point of contact. They’re supposed to triage the inquiry. So Marylouise, you know, sends something in, and I say, gosh, I'm not the right person for this, but I'm going to look them up and look up this member an electronic health record. I'm going to identify their care coordinator, case manager, somebody who knows something about this person. And I'm going to connect them with the hospital. So they provide the hospital or the hospital provides them with contact information so that they can check. And they're supposed to make sure that that conversation happens and keep a log so that when one of us calls, they say, oh no, I have nothing here in my log. I want you to know, this has been in place for over a year, and I am being yelled at on a consistent basis by the MCEs who are staffing this, who said no one ever calls them.
So my goal is to get this information out there, so that they will complain now that you're calling to often, and that would be success for me, frankly. So this is kind of small, but Adam’s given it out to you, but these are the contact information, most of it is email. And I'm sorry, I didn't change Steward Health Choice to Revere, but this is every managed care plan that MassHealth oversees, which I think there are 27 of them. And these are the points of contact for each one. So, some of them, you'll see, like, WellSense has one that they use across all of WellSense, so they're going to need you to tell them which plan, but they are supposed to get back to you. I can't see you, I'm going to ask at the end if anybody has ever used one of these, because I want to buy you a prize.
For barriers related to housing, we have told the managed care staff to be prepared to leverage contracts that they have with housing agencies through their, if it's an ACO, what's called a health related social need services to arrange for or provide assistance completing applications for housing resources, to make referrals to community based agencies, but also to help you in completing those applications for DMH, AGE, or MassAbility I mentioned before. And calling this out as needed, they can and should be paying for an extra day or two in the hospital, and I put that in quotes day or two, maybe a few extra days. If you are working on finding a place for this person to go, they will authorize more stay more days at an administratively necessary day rate. Which I know is not the full rate, but it's better than them not getting anything. So if you know, gosh, I'm working with Marylouise or I'm working with the shelter, and I think we have something in place, and I know I just need a couple of extra days to make that work, the managed care plan supposed to pay for it.
Now, not everybody you work with is on MassHealth, so that's not going to help. I can't control BlueCross BlueShield or any of the private insurers. But I will say, if they're on Medicaid, the managed care plan, will pay for this as will MassHealth, which I'll tell you at the end, for fee-for-service folks. So if the member is admitted to the hospital and they're expected to remain there for 14 or more days, you're supposed to contact the emergency shelter and discuss the person's housing options post discharge. And that shelter, when the person gets there, may be able to say to you, first of all, I know this person, you know, I know that they say they have nowhere to go, but, you know, they just got in a fight with their brother. And here's the brother’s information and it can get resolved. Or they may say to you, that person can’t come back here. Or they may say to you, great, thanks for keeping me in the know. If they're going to be here less than 14 days, then maybe I can figure out, give me a call when you know they're going to be discharged and let's figure out how I can get them, I can't reserve a bed for, you know, ten days. But if they're only in the hospital for a day, let's figure out how they can come back here. So shelters know that if a person is staying there for less than 14 days and you're in your hospital, they are supposed to be working with you on how that person might come back to shelter if they're appropriate.
This doesn't mean you're sending them to a shelter in Boston when the person is in Springfield. This means you're talking to the shelter where they came from, which is local, and saying, hey, you know, they're going to be here and they broke their leg. Well, that's probably not even an overnight nowadays, but they are having laparoscopic surgery. They'll be done in two days, and they'll be fit as a fiddle and be fine to be discharged, let's figure out how to do that. So you cannot hold the bed or reserve the bed but know that the person's coming so you can accommodate them.
If you don't do that, the emergency shelters have no idea what's going on with this person and when you send the person back there, they're going to say sorry. And they may even say sorry, this person's not appropriate, we're sending them back to you. I'm sure some of you are saying that's happened a lot recently. So we're trying to avoid that by making sure that you contact the emergency shelter when the person gets there if the time that they're going to be there is just a short time and we call that less than 14 days. And I do have the link here to all the shelters in the state.
It's important that what we're trying to do is, is make sure that people are not being discharged to shelter if they have to have skilled care needs, they need help with activities of daily living, they have a behavioral health condition that would impact the health or safety of others residing there. Those folks are not appropriate to send to shelter. Other people also might not be appropriate depending on the shelter situation. So if somebody cannot get into a bunk bed and that's the only option, then that might not be appropriate, which is why you need to talk to the shelter and figure that out.
If you have a situation where you have somebody with skilled care needs or they need more, or they have behavioral health conditions, that's where you would be talking to DMH. That's where you would be talking to Marylouise about maybe a nursing home or things like that. So Marylouise's team, she'll tell you all about it, EOHHS discharge can help with that with the folks who are not appropriate to send to shelter. I have seen, unfortunately, or heard of too many discharges to shelter, the person doesn't even get in the front door because their needs are too great and the shelter sends them to the emergency room. So you've got people ping pong all over the place. And that hopefully could be prevented if you guys are working together as a team and communicating.
If you do discharge someone to a shelter, when it's unavoidable or you've worked it out with the shelter ahead of time, there are some rules. One, it can only be during daytime hours, two you're expected to provide a meal prior to discharge and make sure that the person is wearing weather appropriate clothing and footwear. We've had people discharged, you know, barefoot. Now, I know I've heard people say, wait a second, I am not, I was going to say, like Filene’s Basement, but that dates myself. So, I'm not Nordstrom or Marshalls or TJ Max. I don't have a closet in my office filled with appropriate clothing and footwear, and we don't expect you to, but we expect you to make friends with the community organizations such as the shelter. So, for example, I heard about a community meeting where one of the discharge workers from, from the local hospital was saying, how am I going to do this? I don't have clothing. And the shelter provider who was in the meeting said, we do, and we are happy to give it to you, just call us. So really, it's about communication.
Provide the member a copy of their health insurance. Provide them with written copies of their prescriptions. I'm sure you're going to have questions about that. I have some FAQs about that. And one week's worth of film prescription medications. And I'm sure somebody on the phone is saying I'm a hospital that doesn't have an outpatient pharmacy, how am I going to do that? I'll talk about that in a second. Provide at least 24 hours advance notice the shelter, pay for the transportation, and ensure that the shelter has a place for the person. If they don't, but they say, gosh, I know I will have one soon, you can bill MassHealth or the managed care plan for extra days at the administrative day rate to make sure that person doesn't get discharged to the streets.
You are responsible for documenting all of this in the medical record so that if somebody came out, they could take a look at the options you presented to them. If they refused any of those options, that's perfectly fine, too, because I'm going to call you and say, hey, what happened? And you're going to say, I gave them these options, and they said forget about it. If you are a psychiatric inpatient hospital or have a psychiatric inpatient unit, there's DMH reporting that they capture related to discharges to the streets and shelters. And there's also a form online, you may have heard from me that shelters complete, that we research. Just because they complete it doesn't mean it's always the accurate or even, you know, something they may feel is inappropriate, we may say is fine. So again, this is for inpatient admissions only and not for emergency.
Okay. I'm going to go through some frequently asked questions, and I'm going to turn to and then I'm going to do some questions from you all and then turn it over to Marylouise. So some things that you guys often ask, and these are all from online, is what type of patients do the bulletins that do these requirements, apply to. So it's only inpatient admissions. It applies to people who are enrolled in MassHealth, whether they're MassHealth and Medicare, it still applies. So they have to at least be enrolled in MassHealth. It does not apply to Medicare only or commercial insurance.
Does this apply to people who are involuntary committed to a hospital for three days stay? MassHealth recognizes that you may be limited in what you can do in a three day stay, and frankly, the courts get involved. But you're still encouraged to flag any members experiencing homelessness and admission and try and communicate, especially with DMH, if it's a three day stay related to behavioral health issues, still try to communicate.
What's the expected turnaround time from shelters? And I have my, EOHLC, which is the agency that oversees shelters, I do have some spies on today's call so in case in case, you know, they need I could need to call on them, but shelters have been instructed to answer the phone. That's a key thing, right? Sometimes it just rings and rings. Answer the phone when you all call and return voicemails with the overall goal of finding suitable alternatives to placement in shelter. Some of these shelters, just so you know, have a whole workstream related to what they call diversion, which is, you know what? Shelter’s really bad. Don't come here. Let's find you a better place. You have options. You know, your mom kicked you out. But let's call your mom and see. Did she really mean it? Like, let's talk about this. So they have and they sometimes have resources like, oh, you know, you're at the shelter because you broke your, roommate's TV and the roommate kicked you out. Well, we have some funding over here, we’ll buy a TV, and, as long as the roommate will take you back in and we'll say, here's a here's a TV, and therefore, you don't have to come into shelter. So there's a lot of diversion work that happens, and because the goal is not to have people in shelter, I know that it seems like a shelter is the place for a person who doesn't have any place to go, and that makes sense, but if you have ever been to a shelter, it's not a place you would want to go. No offense to my friends in the shelter world. I think they would agree with me. So we really try to keep people who have any alternatives to go that direction instead.
So there are expectations for shelters when they're working with the hospital discharge staff. So they, one of all they can't say to you well that person, they're not from Boston so we're not taking them. However, you should be contacting the local shelter first. Everybody likes to call the Boston shelters, but if you do that, the Boston folks will say to you, have you called the folks in Quincy first? If you're calling from Quincy, they're going to say you need to at least do that due diligence. Don't just call Boston because it's the biggest, you know, where the most shelters are. They can't refuse entry to people who are taking prescribed medications, including opiates and oxygen and benzodiazepine, but know that they really don't have places to store those usually very well. And storing people's belongings is a hard thing to do, and there is nobody on site who is going to do any medication administration management reminders. So if you have somebody who's leaving, who needs somebody to tell them to take his medicine, the shelter is not the right place for them to go. The shelter should be prepared to receive and be receptive to inquiries, to share information about the individual's housing history or other things that they know about them with you, and they're trying to work with you to coordinate placement to the shelter of spaces available.
They should also be receptive to any communication that they're having with you, sorry, I just need to move something on my screen so I can see, to engage in conversation with your staff and coordinate placement even if they don't know that person, if they know the person, then they should be telling you things about them.
Will shelters hold beds? No, short story is no. However, you need to call them as soon as you know that this is going to be an issue. And as soon as you know that they might need to go to a shelter in the end, and start talking to them, because with that information, they should be able to determine if they're able to meet the person's needs in the shelter and when a bed may be available. And if the discharge date is more than two days from the conversation, then you may need to contact them again. But they're going to work with you. Especially if they know this person, they will work with you. You may need to, as I mentioned, have a few extra administrative days at the hospital in order to get that person to wait until that bed is available and we will pay for that if you know, with evidence that you've been working on this.
Are you expected to complete applications for DMH, DDS, and Mass Ability? Yes, you are. However, you should check first to determine if you think that first of all, the person may already be enrolled in those services. so you may not need to, or they might not be eligible. So you might want to talk to the state agency first and see if that makes sense. And back to if they're on a managed care plan, that's a place that we expect the managed care plan or the community partner to actually lean in and be helpful with you. So those are the places DMH, if you're having a problem with DMH applications, you should contact your designated DMH liaison for assistance and completing those applications and accessing DMH resources. Acute inpatient hospitals that don't have a licensed unit, you should contact your local Department of Mental Health. If you're having a hard time in that arena we're also going to talk about how Marylouise and her team can help you as well.
Okay, this is a question about how to pay for those administrative days. So I just want to be clear that you can build those to MassHealth manage and integrated care plans. All of the MassHealth managed care plans, whether they are for duals or whoever they're for, are expected to pay for administrative days so that you can work on the discharge. If a member is duly eligible for Medicare and MassHealth, Medicare does not cover the administrative day, so the claim would cross over to MassHealth to be paid. And if you are working with Fee-for-Service, hospitals are required to split their claims when billing for continued inpatient stay, and you should be pretty familiar with this. So you split between the acute hospital level of care and the administrative AD level of care, and I'm reading this because I'm not an expert, and you must enter in a current span code on your AD claims for the AD level of care stay. Acute hospitals should bill in a current Span Code of 31, along with the Occurrence Span Dates for the members stay. And the member’s status on the last day of acute level care when immediately preceding the AD stay, should indicate the member is still a patient in the hospital. This is all online in the frequently asked questions, but I'm also happy to get you more information if you need on how to do that.
00:33:05:20 - 00:37:38:21
Marylouise Gamache
Okay. All right. Here we go. So as many of you know, we are called EHS Discharge Support. We're a small but mighty team of three folks. And I think and, Ybette and Laurie are here with us today, but we are just, what we like to say to say is, the front door. We work with a lot of colleagues at MassHealth. We work with the Office of Long Term Services and Supports. We work with our plan contract managers. We meet with them frequently and email often. We also work with the DDS and DMH. In fact, our DMH colleagues have now joined some of our hospital meetings. So, we are a collaborative entity.
So I hope you understand that it's a huge team. We are part of a huge team. Here we talked about availability to assist. One of the things, Emily, could you, can we display the intake form, please? Or is that something? Okay. One of the things that helps generate communication with us is a completed intake form. And we use an updated intake form. I know some of you have struggled with the Commonwealth of Massachusetts secure email system. We will walk you through it, but please persevere. I don't see the intake. I can get it.
So, the intake form has a release statement in it, and that allows us to do the research that we need on the individual's health insurance, on reaching out to a DDS or DMH or any of the sister agencies we work with, including HLC, the Housing and Living communities. We will find out where they are on their housing list. We will also find out what their housing application looks like. Somebody may move up on the list if we can show that they are willing to move into a congregate unit, or that they are a veteran, or that they have a disability and need a barrier free unit.
So this green box on our intake form is really critical for you to put a checkmark in there and let us know that you've either got permission from the individual or from their legal representatives and we'll move forward on that. But this is really important. So we appreciate the effort that everybody takes to complete this and send it in to us.
Okay. I think that's it on that, Emily. And one of the other things we want to encourage people to do is to go, go to our website, go to mass.gov, put in discharge support. And I'm going to repeat Emily, please take a look at the resources we have there. We'll review them with you. Will help you out and we'll move forward with that intake review. One of the other things we will do is we will take the intake and we'll share it with a community partner based on a placement. It could be a rest home, it could be a skilled nursing facility, and that's when we hope you will follow up. And Emily, I think we can go to the next page on one of your slides.
That's when we hope that you will follow up with that nursing home or with that rest home, or with that aging services access point and build that bridge. One of the more successful hospitals that we work with is in the Boston area, Mass General. They have a small team, and every intake that we connected them with a nursing home with a managed care plan, a rest home, or even an ASAP - an aging service access point. They followed it up with a phone call and they have a very robust rolodex there right now of community contacts.
The other, entity that, is very helpful. And this is where, Brigham and Women's reached out to us and said, can you help us build bridges with Father Bill's Mainspring with Pine Street Inn? So we will help you do that. We will. Actually, Emily and I will help arrange to have a meeting with the providers in Springfield, in the Lawrence Lowell area, with those providers. One of the benefits of that is you get to meet those people. You get to find out who the ASAP is that's completing your leveling and your PASSRs, and you develop that 1 to 1 relationship, and you are able to move ahead and facilitate things a little bit faster. And I don't see the next slide.
00:37:38:23 - 00:38:18:29
Emily Cooper
I don't know that there is a next slide.
Marylouise Gamache
That's okay. Thank you very much. Just as a closing thing, our email address is EHSdischargesupport@mass.gov. Don't hesitate. Please reach out to us as you many of you know, that is the best way to talk to us, and we will get back to you, and we will set up a meeting. We meet with hospitals routinely across the state. And I'm more than happy to schedule some meetings with your hospital if we're not already meeting there. So thank you very much.