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Temporary Care Settings

An adult with a disability may be discharged from the acute care setting where they received treatment or were quarantined for COVID-19 illness, but required additional lower-acuity care. In this case, they may transition to a temporary care setting prior to returning home, such as a nursing home, an alternate care site, or a hospital swing bed. Examples of promising practices for person-centered discharge planning using the CMIST Framework are outlined in the table below. This is not an exhaustive list of care coordination practices. It is unlikely that every consideration described below will apply to an individual’s discharge plan. For individuals with intellectual and developmental disabilities who use decision-making supports, the discharge planning process should include input from their support system. The applicable considerations and the individual’s specific needs should be communicated to the temporary care setting to which the individual is being transferred.

Communication

The individual has limited English proficiency (LEP)

Your discharge planning process should:

Provide a translator to facilitate appropriate person-centered planning, either in-person or virtually
Have written materials in multiple languages that convey necessary information in plain language
For additional guidance on addressing LEP, please see Ensuring Language Access and Effective Communication during Response and Recovery: A Checklist for Emergency Responders

The individual is deaf, hard of hearing, or is unable to fully use verbal speech

Your discharge planning process should:

Provide an ASL translator, either in-person or virtually
Have written materials to convey necessary information in plain language or use two-way texting devices
If other auxiliary speech or hearing devices, such as hearing aids, are needed, ensure the individual has access to functioning devices

For assistance obtaining technology, see the State Grant for Assistive Technology (AT) Programs

Acquire specialty PPE (if needed) such as clear face masks to facilitate lip reading

The individual is blind or vision impaired

Your discharge planning process should:

Provide written materials in Braille and/or through spoken word

Maintaining Health

The individual has one or more chronic conditions

Your discharge planning process should:

Ensure they have access to appropriate medications or other therapeutics, including DME, as individuals with underlying chronic conditions are at increased risk for severe illness from COVID-19.

The individual requires infection prevention measures

Your discharge planning process should:

Facilitate access to PPE for both the individual and direct service workers (DSWs; if applicable) to reduce the risk of infection
Provide regular screening for COVID-19, and testing for the individual and DSWs (if appropriate)
If the individual is discharged while still COVID+ follow the CDC Guidance on Disposition of Patients with SARS-CoV-2 Infection

The individual requires nutrition services

Your discharge planning process should:

Document the dietary and nutritional needs of the individual, including cultural-appropriate needs to inform the temporary care site

Independence

The individual has a service animal

Your discharge planning process should:

Ensure the service animal can be housed with this individual in their new setting

The individual requires DME

Your discharge planning process should:

Ensure the individual has access to any necessary mobility devices, such as wheelchairs or walkers, and other DME
For an assessment to address functional needs, see the State Grant for Assistive Technology (AT) Programs

The individual uses alternate strategies to maintain independence

Your discharge planning process should:

Discuss and plan with the individual for alternative forms of support such as access to picture cue cards or a daily schedule

Support

The individual has been separated from family or caregivers due to social distancing requirements

Your discharge planning process should:

The individual may experience increased anxiety or other psychological distress and therefore need additional behavioral health supports that are delivered in an accessible, culturally competent manner
For social programs and technologies, see the Aging and Disability Resource Centers (ADRCs) / No Wrong Door System, or other local coordinating entity. If visitation is allowed, ensure the individual has opportunities to see their family or caregivers in a manner consistent with infection prevention measures
If visitation is not allowed, provide technology and technological assistance (if needed) to facilitate virtual visits

For social programs and technologies, see the Aging and Disability Resource Centers (ADRCs) / No Wrong Door System
Under Sec 3715 of the CARES Act, an individual’s personal aides may accompany them to hospitals. For more information see page 39 of COVID-19 Frequently Asked Questions (FAQs) for State Medicaid and Children’s Health Insurance Program (CHIP) Agencies

The individual will be discharged home or to another care setting

Your discharge planning process should:

Clearly state the indicators for when they can be safely discharged to help prevent unnecessarily long stays or institutionalization
The individual may experience increased anxiety or other psychological distress from changes in physical environment. Discuss and plan with the individual and support system the additional behavioral health supports needed

Discharge Planning & Care Coordination During COVID-19