Managed care plans and PACE organizations must ensure network hospitals implement the following discharge planning procedures for members experiencing or at risk of homelessness:
Assess housing status at admission; hospitals must assess each admitted member's current housing situation and at a minimum determine whether the member is experiencing or at risk of homelessness.
Screen admission data within 24 hours of admission; discharge planning staff must screen admission data (including but not limited to age, diagnosis, and housing status) within 24 hours to aid identification.
Commence discharge-planning activities no later than three working days after admission for any member identified as experiencing or at risk of homelessness, unless earlier action is required.
Contact managed care plan or PACE organization at time of admission to collaborate on identifying resources to assist with the member's housing situation.
Invite and encourage participation in discharge planning, consistent with applicable privacy laws, from the member, family/guardians, primary care and behavioral health providers, key specialists, Community Partners, case managers or other representatives, emergency shelter outreach or case management staff, care coordinators, and other supports identified by the member; for DMH/DDS/MRC clients, invite designated agency staff.
Within two business days of admission, offer to assist eligible non‑agency‑involved members with completing and submitting applications to DMH, DDS, or MRC, as appropriate, consistent with privacy laws.
If the member has a substance use disorder, contact the DPH Helpline ((800) 327‑5050) to assist with treatment, recovery resources, and options.
For members expected to remain fewer than 14 days, contact recent or local emergency shelters and use the shelter contact resources provided online to identify placement options.
Make reasonable efforts to avoid discharging members who have skilled care needs, need assistance with activities of daily living, or whose behavioral health conditions would impact shelter safety to emergency shelters; seek alternative placements such as DMH community programs or skilled nursing facilities.
ALL of the following
Discharge the member only during daytime hours.
Provide the member a meal prior to discharge.
Ensure the member is wearing weather‑appropriate clothing and footwear.
Provide the member a copy of their health insurance information.
Provide a written copy of all prescriptions and at least one week's worth of filled prescription medications when clinically appropriate and consistent with applicable laws and regulations.
If discharging to an emergency shelter: provide at least 24 hours advance notice to the shelter; provide access to paid transportation to the shelter; ensure the shelter has an available bed. If a bed is unavailable but will be available soon, delay discharge until the bed is available; hospitals may bill the managed care plan or PACE organization at the Administratively Necessary Day (AND) rate for each day the member remains in the hospital pending bed availability.
Document and track discharge planning activities: document all efforts related to discharge planning in the member's medical record (including options presented and any refusal of alternatives) and track discharges to local emergency shelters or the streets in the form, format, and cadence specified by MassHealth.
Provide regular training and resource guides to discharge planning staff and utilize available community resources and MassHealth/DHCD/ICHH tools, toolkits, decision tools, letters to shelters, reporting forms, support lines, and online guides to assist discharge planning and placements.