Care transitions are especially important to persons needing LTSS because a transition often determines where the person will live.  If the beneficiary receives adequate support before and during the transition process, he or she will more likely be able to return to, or move to, a house, apartment, or other non-institutional setting.  On the other hand, poor transitions are likely to result in hasty institutional placements, or badly supported attempts to return to the community and further institutionalization, which for some individuals means that they will never live at home again.

  • Prior to an individual’s discharge from a hospital or a nursing facility, an MCO must present him or her with the full range of appropriate and available options, including HCBS.  Likewise, an MCO must ensure that it’s participating providers, particularly hospitals and nursing facilities,  present enrollees with the full range of appropriate and available options once the individual’s condition has sufficiently stabilized and prior to discharge.  An individual’s preferences must be honored, pursuant to applicable service planning procedures.
  • Prior to an individual’s discharge from a hospital or nursing facility, an MCO must ensure that an individual’s service needs have been appropriately assessed and that a transition plan has been prepared.  Accordingly, an MCO must require that its participating hospitals and nursing facilities ensure that an individual’s services needs have been appropriately assessed prior to discharge and that a transition plan has been prepared.  Development of transition plans should follow service planning requirements, particularly those relating to an individual’s participation and appeal rights.
  • MCOs must ensure that appropriate LTSS are available immediately upon discharge.
  • MCOs must pay retainer payments or employ similar mechanisms to ensure that LTSS providers are available to re-start services when an individual returns from a hospitalization or nursing facility stay.  This obligation must apply equally when the LTSS provider is an assisted living facility or similar setting; in that case, the state obligation applies both to service costs and to room and board expenses.
  • When an individual is living in a participating assisted living facility or similar setting, and then is hospitalized or admitted to a nursing facility, the assisted living facility or similar setting must honor the individual’s rights under the admission agreement and/or relevant state legal protections to retain possession of the living unit in the assisted living facility.  As necessary, the assisted living facility or similar settings must offer a room hold.  MCOs must require that participating providers adopt and follow such policies, and alter any existing contractual requirements that state a contrary policy.
  • MCO benefit packages must include coverage for expenses related to care transitions such as moving expenses and home modifications.
  • As necessary, states and MCOs must offer a benefit that would allow individuals to retain their house, apartment or other community-based setting during a hospitalization or nursing facility stay, in situations where expenses (or other factors) associated with the hospitalization or nursing facility stay otherwise would not allow individuals to maintain the house, apartment, or other setting.
  • MCOs must find and support community-based “transition-out” programs to move individuals when appropriate to community-based settings from nursing facilities and other institutions, and develop such programs where they do not exist or exist only at a rudimentary level.  Peer support should be an integral component of such programs.
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