transcript  Discharge Planning Policies

Discharge Planning Policies Video Transcript

Discharge Planning Policies – Understanding the new MassHealth policies regarding hospital discharge planning with patients experiencing homelessness or housing instability.

Because homelessness impacts not only an individual’s health but also can result in high costs for the healthcare system, the primary goal of discharge planning should be to  prevent discharging individuals into homelessness, whether they were homeless, at risk of homelessness or housed when they first entered the hospital.  This includes hospital staff

  • identifying strategies to help patients maintain their housing while hospitalized.
  • making  every effort to avoid discharge to a shelter or the street. 
  • taking steps to identify and offer appropriate alternative options to a patient and documenting  such measures, including the competent refusal of alternative options by a patient, in the medical record. 

As required by the federal government and MassHealth, discharge planning must begin at admission to the hospital. For individuals with a history of homelessness or housing instability, this admission should include a discussion around safe current living arrangements; with this early planning some housing situations can be preserved while the individual is hospitalized.

Understanding the challenge of addressing homelessness, the MassHealth guidance distinguishes between  those patients who have short inpatient stays (less than 14 days) and those that have longer stays  (more than 14 days),  as well as those who were homeless or housing unstable when they entered the hospital.

For patients that were housed prior to admission, it may be possible to retain the housing by speaking with the landlord or housing agency and working out a plan for paying the rent (or accessing housing assistance programs if the patient has no available resources). 

For patients who were homeless prior to admission and have short hospitalization stays, discharge planning should include a discussion with the local emergency shelter about whether the patient could return after the hospitalization. 

For patients who have long hospitalization stays,, discharge planning should include discussions with family, friends, and any person with a relationship with the patient that may have resources and/or willingness to help provide a housing option. This would include contacting any involved case managers and helping the patient apply for available resources for which they may be eligible. 

Hospital staff are expected to coordinate the discharge planning process with the patient’s support systems, state agencies, insurance plans, community-based providers, and at times shelter staff. Early and frequent communication with these agencies, particularly those that also have a relationship with the patient, is integral to preventing patients from becoming homeless after discharge. 

The following slides share specific resources with which to coordinate, depending on the patient’s specific needs. Remember that you can visit these resources at any time by visiting the Helping Patients who are Homeless or Housing Unstable page on the website.

For patients that are insured, discharge planning should include outreach to the health insurance plan to determine if the plan may be able to provide resources, assist in completing housing or service applications, or help identify solutions to assist with housing. MassHealth has issued specific guidance to MassHealth managed and integrated care plans that require them to work collaboratively with hospital staff to identify an appropriate setting post hospitalization and to ensure a smooth discharge.

For patients who were homeless or housing unstable prior to admission and will need skilled or long term care upon discharge, go to Helping Patients with Skilled Nursing or Other Long Term Care Needs.

It is important to note that patients that need assistance with Activities of Daily Living or have behavioral health issues that would impact the health and safety of others in shelter should not be discharged to a shelter.

For patients with serious mental illness, the hospital should contact the local Department of Mental Health (DMH) Area Office to determine if the patient is a DMH consumer and to identify potential housing and/or respite resources. If the patient is not already a DMH consumer, consult with the local DMH Area office to determine if a DMH application for services is appropriate. 

For patients with developmental or intellectual disabilities, the hospital should contact the local Department of Developmental Services (DDS) Area Office to determine if the patient is a DDS consumer and to identify potential housing and/or respite resources. If the patient is not already a DDS consumer, consult with the local DDS Area office about completing and submitting a DDS application for services.

For patients with traumatic or acquired brain injuries, the hospital should contact the Massachusetts Rehabilitation Commission (MRC) to determine if the patient is a MRC consumer and to identify potential housing and/or respite resources. If the patient is not already a MRC consumer, consult with the MRC office about applying for MRC community-based services.

For patients with substance use disorders, the hospital should contact the DPH-sponsored Helpline (800-327-5050). Helpline is the statewide, public resource for finding substance use treatment, recovery programs, and assistance with problem gambling. The Helpline’s trained specialists will help the patient understand the treatment system and their options.

For patients in need of MassHealth coverage, information on the application process can be found on the website. For further assistance with coverage or eligibility issues, please contact the MassHealth Customer Service Center (800) 841-2900

Where the patient appears to be eligible for insurance or services from a state agency but has not yet submitted an application for such insurance and/or services, hospital staff should offer to assist the patient with completing and submitting applications within two business days of admission regardless of anticipated length of stay. 

Shelters are vital partners in reducing discharges into homelessness and for ensuring that vulnerable individuals without alternatives have a safe place to sleep at night. Early and frequent communication between hospital and shelter staff has proven effective in reducing inappropriate discharges to shelter and better ensuring those who are discharged are prepared for a safe and successful stay. For any member who was experiencing homelessness prior to admission, the acute care or psychiatric inpatient hospital must contact the shelter within two days after admission.

When discharging a patient to the shelter, the hospital must contact the shelter at least 24 hours prior to discharge

When a patient will be discharged to shelter, MassHealth has outlined protocols that hospitals are expected to follow:

  • Hospital discharge staff provides the shelter with at least 24 hours advance notice prior to discharge. 
  • The patient is discharged during daytime hours. 
  • The patient is provided with access to paid transportation to the emergency shelter.
  • The patient is provided with a meal prior to discharge. 
  • Ensure that the patient is wearing weather appropriate clothing and footwear. 
  • The patient is provided with a copy of their health insurance information. 
  • The patient is provided with a written copy of all prescriptions and at least one week’s worth of filled prescription medications. 

It is likely you will need a release of information from the patient in order to advocate on their behalf with state agencies and shelter staff.

It is recommended that you secure a release as early in the patient’s stay as possible so such planning can begin early in their hospital stay.