Transfers and Discharge Planning

(A) Discharge Procedures. (1) A member shall be discharged by the home health agency provider under the following conditions: (a) upon the member’s request; (b) if the member ceases to benefit from home health services; (c) if the member no longer meets the clinical eligibility for home health services; (d) if the member selects another MassHealth service that is duplicative of the home health the member is receiving, including MassHealth services that provide assistance with personal care; (e) if the member transitions completely to another home health provider or CSN provider or combination of providers; or (f) if the home health agency ceases operations. (2) A member may be discharged by the home health agency provider if the home health agency cannot safely serve the member in the home in accordance with 42 CFR 484.50(d)(5). (B) Safe Discharge Planning when other Community Services Needed. Home health agencies must (1) begin to develop a discharge and transition plan for members during the admission process/start of care; (2) coordinate community long-term services that are most appropriate for the member’s needs at discharge and refer to other community services accordingly; (3) provide assistance to the member in identifying and locating other community long-term services; (4) document coordination with community resources and keep documentation of referrals to other community resources in the member’s record; (5) coordinate the discharge and transition with the member, member’s family/caregiver, and the staff of the provider, program or agency to which the member is to be transferred; and (6) make best efforts to ensure the continuity of care until the new service has commenced. (C) Discharge Planning Requirements for Members over 21 Years of Age Utilizing Home Health Aide Services for ADL Supports Only. In addition to complying with the discharge requirements established in 130 CMR 403.422(A) and 130 CMR 403.422(B), home health agencies providing home health aide services for ADL supports only must also (1) complete a Member Connection Form as designated by the MassHealth agency, and send to the member’s waiver program (as applicable) or to the member’s local ASAP for evaluation or options counseling; (2) establish an individualized discharge plan at the start of services. The member’s discharge plan must be reviewed and updated as the member’s discharge from home health services approaches; (3) assist the member in locating and securing long-term personal care services, if needed. (D) Members 60 Years of Age or Older. Home health agencies must complete a Member Connection Form for those MassHealth members 60 years of age or older within 15 days of a planned discharge from home health services or whenever the agency determines that the MassHealth member could benefit from ASAP services. See 651 CMR 14.00: Aging Services Access Points, for a description and definition of ASAP. Home health agencies shall forward the completed referral form to the ASAP serving the area in which the member resides and must keep a copy of the completed ASAP referral form in the member’s record. (E) Transfers of Members to Alternate Home Health Agencies. (1) When a member transfers from one home health agency to an alternate home health agency, the transferring home health agency must inform MassHealth within 10 days of the transfer. When informing the MassHealth agency of the transfer, the transferring home health agency must include the following information in the form and format required by the MassHealth agency and maintain this information in the member’s record: (a) Member Name; (b) Member ID; (c) Member care plan; (d) Receiving home health agency; (e) Date of transfer; and (f) Reason for transfer. (2) The receiving home health agency must complete an initial member assessment and must obtain prior authorization. The new agency must collaborate with the transferring agency in regards to the prior authorization timeline, number of visits completed, and must ensure that there are no overlapping dates of service.