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Discharge Planning and Care Coordination During the COVID-19 Pandemic

Maintaining Services for Adults with Disabilities Who Live in Community Settings

This tool is designed to support nurses, social workers, case managers, and others conducting effective discharge planning and care coordination for adults with disabilities who received care or treatment for COVID-19 illness in an acute care setting, are no longer COVID-19 positive, and require continuation or reconnection to supports and services. While not exhaustive, the resources and considerations proposed in this tool comprise promising practices to be addressed when practicable.

Adults with disabilities who live in community settings often have an established network of long-term supports and services (LTSS), home and community based services (HCBS), and other supportive service programs for independent living. During the COVID-19 pandemic, individuals may become separated from these supports and services if they move to alternate settings for isolation, quarantine, or medical care due to COVID-19 illness (see the journey map for potential paths people may take).

As a nurse, medical social worker, or case manager, you may be responsible for discharge planning of adults with disabilities during the COVID-19 pandemic.1 This resource will provide you with strategies to consider and resources to leverage for care coordination during the discharge planning process. It also includes a brief summary of the laws protecting individuals with disabilities and related requirements. These strategies can facilitate the reestablishment of needed services upon discharge home, to temporary care settings, such as a nursing home or swing bed hospital, or to new housing. The resource also includes contact information for connecting to community-based aging and disability network organizations, which may be helpful partners in supporting people with disabilities returning home post-discharge.

This resource provides tips for healthcare providers developing person-centered discharge plans for adults with disabilities who required treatment for COVID-19 illness in acute care settings. These tips include using a suggested framework, as well as an overview of state-level programs, national resource centers, and federal contacts to support discharge planning and care coordination.

1 An individual with a disability is someone who has a physical or mental impairment that substantially limits one or more major life activities. Note that persons with cognitive, vision, hearing, and speech impairments may have specific communication needs.