GAFC Discharge Procedures

(A) A member must be discharged by the GAFC provider upon the member’s request, or if the member ceases to benefit from GAFC, including the following circumstances: (1) the member no longer meets the clinical eligibility criteria for GAFC; (2) the member demonstrates behavioral or other problems that may endanger the member or GAFC provider staff; (3) the member’s clinical needs are beyond the scope of GAFC; (4) the member’s needs cannot be met by the GAFC provider; (5) the member selects another service which is duplicative of GAFC; or (6) the member transitions to another GAFC provider. (B) For all discharges, the GAFC provider must: (1) develop a discharge and transition plan, which must: (a) include the date and reason for discharge; (b) identify any referrals by the GAFC provider to other appropriate service providers for any health or social services required by the member; (c) ensure continuity of care by the member, including during transitions of care, as specified in the GAFC plan of care; (d) be dated and signed by the GAFC registered nurse, the GAFC care manager, and the member; and (e) require at least one follow-up telephone call within 30 business days after discharge to determine the member’s post-discharge status and condition; (2) provide assistance to the member in identifying and locating another provider; (3) arrange for the member to be discharged and transitioned to the provider identified in 130 CMR 408.523(B)(2); (4) coordinate the discharge and transition with the member, member's family or legal guardian, and staff of the program or agency to which the member is to be transferred; and (5) maintain current services until the member is admitted with a new provider.