Discharge Planning
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This policy governs San Francisco Health Plan's (SFHP) discharge planning and care coordination processes for eligible members across listed lines of business, ensuring medically safe and coordinated transitions from acute and post-acute settings to community care.
No material clinical or coverage changes in this revision.
Discharge Planning Criteria
Discharge Planning Operational Criteria
Criteria and procedural steps for discharge planning and referrals
ALL of the following
Risk assessment
- Use BOOST Project 8Ps risk assessment tool in conjunction with Concurrent Review Nurse clinical judgment to assess readmission risk.
Risk-based referral
- Members assessed as moderate-to-high risk for readmission and requiring intensive care coordination are referred to Enhanced Care Management (ECM), Transitional Care Services (TCS), or the Care Management Department for short-term or long-term interventions or other appropriate external programs.
- Referrals to Care Management follow the Care Management Program Descriptions (see CARE-01, CARE-04, and CARE-05).
Coding and Measurement Notes
| No codes listed |
Required Provider Actions and Monitoring
Discharge planning actions required by CCR nurses and Clinical Operations
Clinical Operations Concurrent Review (CCR) Nurses must conduct patient-centered assessments at admission to identify discharge planning needs and document pre-admission status, pre-/post-discharge factors, services needed, placement preferences, member involvement, anticipated implementation issues, and DME needs. CCR Nurses or Coordinators must schedule and communicate post-discharge PCP appointments with the member or facility staff, and when facilities lack Care Everywhere access, SFHP must forward the discharge summary or latest clinical information to the PCP prior to the post-discharge appointment. Members identified as moderate-to-high risk for readmission (using CCR clinical judgment plus the BOOST 8Ps) must be referred to ECM, TCS, or the Care Management Department for short- or long-term interventions per Care Management program descriptions.
- Conduct patient-centered assessment at admission for hospital, SNF, or institutional admissions (includes living donor admissions for major organ transplant).
- Document pre-admission status (living arrangements, physical/mental function, social support, DME, other services) and pre-/post-discharge factors (understanding of conditions, financial resources, supports).
- Record services needed after discharge, placement type preferred and agreed, recommended discharge setting, and pre-discharge counseling.
- Summarize member/representative involvement and anticipated problems implementing post-discharge plans.
- Schedule and communicate post-discharge PCP appointments; forward discharge summary to PCP if facility lacks Care Everywhere access.
- Use BOOST 8Ps plus clinical judgment to stratify readmission risk; refer moderate-to-high risk members to ECM, TCS, or Care Management (per CARE-01/CARE-04/CARE-05).
Definitions and Tools
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