Guidance on Discharge Planning

• Guidance is also available in Portable Document Format (PDF)

NEW YORK STATE DEPARTMENT OF HEALTH CERTIFIED MEDICAL RESPITE PROGRAM

The Department of Health (Department) adopted new regulations at 10 New York Codes, Rules and Regulations (NYCRR) §1007.8 that define discharge planning standards for certified medical respite programs. This guidance document is intended to clarify and supplement the Department's regulations. Each medical respite program must establish a discharge planning policy that complies with the regulations and this guidance.

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DISCHARGE PLANNING

Overview of Discharge Planning
The medical respite program must engage in discharge planning throughout the entire stay of each recipient. At the time of admission, the medical respite program will review all documentation provided by the referring entity and discuss with the recipient the recipient's goals and plans for discharge. Using this information, the medical respite program will create a service plan with discharge indicators. (See the Department's Guidance on Referrals, Assessments, and Service Plans for more details.)

All discharge indicators should be met before the medical respite program discharges the recipient, except as described under "Discharge" and "Involuntary Discharge" on pages 3 through 6 of this guidance.

Discharge Planning and Housing
The medical respite program must make good-faith efforts to discharge a recipient to housing that is reasonably acceptable to the recipient and is safe and stable. Safe and stable housing means housing that does not jeopardize the health, safety, or welfare of the recipient; that permits access to electricity, heat, and running water for the benefit of the recipient; and for which the recipient has a written lease, sub-lease, mortgage, or rental agreement with tenant, owner, or other property rights.¹

The medical respite program will satisfy the good-faith requirement when it can document that staff provided or arranged, either directly or through coordination with other service providers, for the recipient to:

• Submit applications for housing and attend housing interviews;
• Submit applications for social support benefits or entitlements for which the recipient may be eligible and facilitate the individual's receipt of those benefits or entitlements;
• Retain legal support services (for example, as related to immigration, housing, public benefits) if appropriate;
• Receive vocational support or training (for example, via Access-VR), if appropriate; and
• Receive care coordination services (for example, from Assertive Community Treatment (ACT) Team, health home, managed care organization (MCO), and/or social care network (SCN), if appropriate.

The medical respite program may not discharge a recipient to a homeless shelter or to unsheltered homelessness unless:

• The recipient does not qualify for safe and stable housing (for example, the recipient is an undocumented immigrant and has met with an immigration lawyer to confirm there is not currently a pathway to legal status);
• The recipient does not cooperate with the medical respite program's efforts to secure safe and stable housing (for example, the recipient refuses to provide necessary information or attend housing interviews); or
• After good-faith efforts to secure safe and stable housing, the medical respite program is unable to secure such housing.

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ADVANCE WRITTEN NOTICE OF DISCHARGE

Pursuant to 10 §NYCRR 1007.8(a)(4)(ii), the medical respite program must provide advance written notice of discharge to the recipient at least 14 days prior to discharge, except:

• If the recipient's length of stay is expected to last less than 14 days, the medical respite program should provide written notice of the anticipated date of discharge at the time the recipient is admitted; or
• If the recipient is found to meet criteria for involuntary discharge, the medical respite program should discharge the recipient to an appropriate location as soon as is practicable. (For more information, see "Involuntary Discharge" on page 6 of this guidance.)

The discharge notice must provide all of the following:

• Discharge reason;
• Housing identified for the recipient after discharge (including any homeless shelter or unsheltered homeless locations);
• Appeal rights of the recipient, including:
  • Detailed instructions on how to appeal the discharge, and
  • Referrals for assistance or representation with the appeal.

The discharge notice must also comply with all notice requirements set by State and federal laws and any relevant regulations and guidance set by the Department. If the Department provides a sample discharge notice, that sample notice should be used as a template for the medical respite program's discharge notice. The medical respite program should ensure it uses the most current version of the sample discharge notice (available on the Department's Medical Respite Program webpage).

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DISCHARGE

The medical respite program must discharge a recipient when:

• The recipient no longer qualifies for medical respite services, as defined in 10 NYCRR §1007.2 and §1007.7 and the Department's Guidance on Referrals, Assessments, and Service Plans;
• The recipient has exhausted all possible sources of funding for medical respite care; or
• The recipient is ready for the next level of care (in cases where a recipient is receiving pre- procedure care, as described in the Department's Guidance for Referrals, Assessments, and Service Plans).

In certain circumstances, the medical respite program is permitted to discharge a recipient even if all discharge indicators have not been met or safe and stable housing has not been identified. These circumstances may include:

• If the medical respite program identifies safe and stable housing for the recipient, then the must be discharged as soon as the housing placement is available and any critical services needed to support the recipient immediately post-discharge (e.g., home health care) are in place.
  • The medical respite program must coordinate with the managed care organization, health home, Social Care Network, or other care management entities to have appropriate services provided at the recipient's safe and stable residence. Such services may be related to any unmet physical health, mental health, substance use, or social care needs identified in the recipient's service plan.
  • The medical respite program should coordinate with the recipient's primary care, behavioral health, substance use treatment, and social service providers, as appropriate, to facilitate timely and consistent care for the recipient throughout their transition to permanent housing.
• If the recipient's qualifying medical condition has resolved such that they could be safely discharged, and the recipient is found to have no additional qualifying medical conditions, then the recipient no longer meets eligibility criteria for medical respite services and must be discharged.
  • Safely discharged means that the recipient is not at risk of health deterioration and is unlikely to require emergency department care or hospitalization if they return to sheltered or unsheltered homelessness.
    • If the medical respite program is unsure whether the recipient's qualifying medical condition is resolved, the medical respite program should obtain confirmation from the recipient's primary care provider or another licensed health care provider who is not under contract with or in the employ of the medical respite provider and who is familiar with the recipient and their condition(s).
    • If this confirmation is obtained verbally, it should be documented in the recipient's record; the documentation must include the name of the provider, the date confirmation was received, and the name and signature of the person who received confirmation.
  • The medical respite program must provide, to the extent practicable, any housing packets or other pending social services information to the homeless shelter or, in the event the recipient is not discharging to a shelter, to another entity that can continue to assist the recipient after discharge (such as a managed care organization, health home, Assertive Community Treatment (ACT) Team, and/or Social Care Network).
• If the medical, behavioral, or social needs of the recipient are higher than the medical respite program initially assessed or become higher during the recipient's stay such that the medical respite program cannot meet the recipient's needs, the recipient must be discharged; however, the recipient must not be discharged to a congregate homeless shelter or unsheltered homelessness.
  • The medical respite program must coordinate with the managed care organization, health home, and/or Social Care Network, and other service providers as needed to locate an appropriate placement, such as a medical respite program equipped to offer greater support services, a rehabilitation facility, skilled nursing facility, or inpatient substance use treatment program.
  • The medical respite program must provide, to the extent practicable, any housing packets or other pending social services information to the transfer location and/or other entities involved in the recipient's care management, as appropriate.
• If the recipient has reached the maximum length of stay set by the payor and has not recuperated sufficiently to be safely discharged, and no additional sources of funding for medical respite are available, the recipient may be discharged; however, the recipient must not be discharged to a congregate homeless shelter or unsheltered homelessness.
  • The medical respite program must coordinate with the managed care organization, health home, and/or Social Care Network, and other service providers as needed to ensure an appropriate placement with necessary support services, such as a rehabilitation facility, skilled nursing facility, or inpatient substance use treatment program.
  • Safely discharged means that the recipient is not at risk of health deterioration and is unlikely to require emergency department care or hospitalization if they return to sheltered or unsheltered homelessness.
    • If the medical respite program is unsure whether the recipient can be safely discharged, the medical respite program should seek a determination from the recipient's primary care provider or another licensed health care provider who is not under contract with or in the employ of the medical respite program and who is familiar with the recipient and their condition(s).
    • If obtained verbally, this determination should be documented in the recipient's record; the documentation must include the name of the provider, the date the determination was received, and the name and signature of the person who received the determination.
  • The medical respite program must provide, to the extent practicable, any housing packets or other pending social services information to the transfer location and/or other entities involved in the recipient's care management, as appropriate.
• If the recipient was admitted for pre-procedure care only, and the recipient is now ready to undergo the scheduled procedure, the recipient must be discharged to the facility where the procedure will take place.
  • The medical respite program must provide, to the extent practicable, any housing packets or other pending social services information to the transfer location and/or other entities involved in the recipient's care management, as appropriate.
• If the recipient was admitted for pre-procedure care only, and the recipient's scheduled procedure is canceled, the medical respite program must evaluate whether the recipient has continued need for medical respite care, taking into consideration the status of the procedure (i.e., permanently canceled versus postponed) and any other qualifying conditions the recipient may have.
• If the recipient wants to be discharged from the medical respite program, they may move out at any time. The recipient should inform the medical respite program of their decision to leave. The medical respite program should support the recipient's decision and provide any documentation or transfer assistance typically provided to discharging recipients.

In all cases, the recipient should be engaged throughout the discharge planning process, and the preferences of the recipient regarding placements or transfers must be considered. If the recipient has someone else designated or appointed to help them make informed decisions about their care, that representative must also be consulted about the discharge plan.

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INVOLUNTARY DISCHARGE

A recipient may be involuntarily discharged, as permitted by 10 NYCRR §1007.8(d)(5) and described below. If a recipient meets the criteria for involuntary discharge, the medical respite program may discharge the recipient without providing 14 days' advance written notice of discharge and even if all discharge indicators have not been met and safe and stable housing has not been identified for the recipient.

The medical respite program may involuntarily discharge under any of the following circumstances:

• The recipient has a known absence lasting 72 hours or longer.
  • A known absence occurs when the recipient leaves the medical respite program, and the medical respite program is aware or becomes aware of the reason for the recipient's departure. A known absence may result from the recipient's arrest, detainment, hospitalization, or reunification with family, among other scenarios.
  • The medical respite program must document the recipient's absence and include any documentation or verification that the absence persisted or was going to persist beyond 3 days (72 hours).
• The recipient has an unknown absence lasting 48 hours or longer.
  • An unknown absence occurs when the recipient leaves the medical respite program without notifying program staff, the medical respite program cannot locate the recipient, and the recipient has not responded to the medical respite program's attempts at contact via phone, text, or email.
  • The medical respite program must document the recipient's absence, including any verification that the absence persisted beyond 2 days (48 hours), and make and document multiple attempts to contact the recipient, the police, hospitals, and any known emergency contacts.
• The recipient develops a communicable disease subject to federal, State, or local isolation and quarantine laws. The communicable disease must be diagnosed by a licensed health care provider. The medical respite facility must discharge the recipient to an appropriate treatment facility in accordance with federal, State, or local isolation and quarantine laws.
• The recipient's behavior poses an imminent risk of death or serious physical harm to the recipient or others. The medical respite program must document the risk of harm to self or others and take appropriate steps to protect the recipient, medical respite program staff, and the public (for example, by referring the recipient to inpatient psychiatric care).

In all cases, if the recipient has someone else designated or appointed to help them make informed decisions about their care, that person must also be notified regarding the involuntary discharge.

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APPEALS

Pursuant to 18 NYCRR Part 358, medical respite recipients who are enrolled in the New York State Medicaid Program have the right to appeal a discharge decision. The procedure for filing an appeal varies depending on the payor funding the recipient's medical respite services.

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DISCHARGE SUMMARY

The discharge summary must contain, at a minimum, all elements set forth in §10 NYCRR 1007.8(b), including:

• Written medication list and refill information (such as pharmacy name, address, and phone number), to the extent known;
• Admitting diagnosis;
• Length of stay in the medical respite program;
• Ongoing medical problems or conditions, to the extent known;
• Instructions for accessing relevant resources in the community, including shelters or other housing options;
• List of follow-up appointments and contact information for treating providers, to the extent known;
• Special medical instructions (such as weight-bearing limitations, dietary precautions, allergies, wound care orders, pain management plan), to the extent known; and
• Primary point(s) of contact for the recipient.

To the extent possible, the discharge summary should be provided at least 14 days prior to discharge.

The discharge summary must be provided to the recipient and (with signed consent from the recipient) any designated representatives, entities involved in the recipient's care management, and providers, such as:

• The recipient's primary care physician;
• The specialty physician who has been overseeing care for the recipient's health condition, or the specialty physician who has been designated as the recipient's follow-up provider following a hospital discharge, if applicable;
• The recipient's behavioral health provider, if any;
• The recipient's substance use disorder treatment provider, if any;
• The recipient's caregiver or family member, if any;
• The managed care plan, if any;
• The health home, if any;
• The referring entity; and
• The discharge location (for example, family, housing, shelter).

To the extent possible, the discharge summary should be transmitted electronically to the individuals and entities listed above, provided that any electronic transfer of information complies with HIPAA.

Change of Address Notification
In preparation for the recipient's discharge, the medical respite program will also be expected, contingent on written consent from the recipient, to assist the recipient with notifying relevant entities of any change of address. Such entities may include, but are not limited to:

• The persons and entities required to receive the discharge summary as well as any social services with which the medical respite program is currently working to assist the recipient;
• The New York State of Health Marketplace, if applicable, to ensure the recipient continues to receive Medicaid notices and timely renewal information;
• The Local Department of Social Services, if applicable, to ensure the recipient continues to receive any relevant notices and renewals (for example, for SNAP, WIC, Temporary Assistance);
• The Social Security Administration, if applicable, to ensure the recipient continues to receive benefits; and
• Any other relevant offices or departments to ensure the recipient continues to receive timely notice.

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DOCUMENTATION AND RECORDS

Pursuant to 10 NYCRR §1007.14, the medical respite program must maintain all records related to discharge, including:

• Documentation of discharge planning;
• Efforts to secure housing for the recipient; and
• All services provided or coordinated for the recipient.

The medical respite program should carefully document any refusal by the recipient to engage with discharge planning, housing applications or interviews, or service provision and coordination. The medical respite program should expect the recipient's engagement to be at a reasonable level considering any medical condition(s), disabilities, or impairments the recipient has. The medical respite program is expected to make multiple attempts to engage the recipient throughout the stay and to provide as much support to the recipient as possible.

All records of discharge should include, at a minimum, the:

• Discharge summary;
• Notice of discharge and list of who received such notice, with relevant signed release/authorization;
• Reason for discharge;
• Location of discharge (such as shelter, housing);
• Notice of address change and a list of who received such notice; and
• Other relevant information regarding the recipient's discharge.

The medical respite program must maintain records related to discharge for a minimum of 6 years. Records may be maintained electronically.

Upon request by the Department, the medical respite program must provide a summary of each recipient's length of stay, discharge reason, and discharge location using any template reporting form provided by the Department.

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^{1. This definition of safe and stable housing is adapted from DC Code §4-751.01(32B) (2023) and 24 CFR §578.3. 1}

Updated August 2024