Discharge Planning

(A) The psychiatric inpatient hospital must assign, in writing, the responsibility for all member discharge planning to one department (such as social services or continuing care). (B) Admission data, including but not limited to age and diagnosis, must be screened by discharge-planning staff within 24 hours of admission in accordance with written criteria that identify pertinent patient characteristics and any high-risk diagnoses. Discharge-planning activities must then commence within three working days of admission for every member expected to require post-hospital care or services. Admission data must be noted in the member's record by the discharge-planning department. The written criteria used to screen members must be available to the MassHealth agency. (C) The hospital's discharge-planning staff and interdisciplinary review team must coordinate and document, in writing, a plan for each member who requires post-hospital care. Such plan must be prepared by the hospital's interdisciplinary review team, in conjunction with any primary care provider, DMH, DCF, DYS, or DDS case managers, and must ensure continuity of care with the member's family, school, and community upon discharge. The plan must also specify the services and care required by the member and the frequency, intensity, and duration of such services, including available family and community support. The plan must be updated if the member's condition changes significantly. The hospital must ensure that a clinician certified in accordance with 130 CMR 425.412 completes a CANS during the discharge planning process for members younger than 21 years of age. (D) The hospital must have a written policy that allows discharge-planning staff access to all members and their medical records. If such access is clinically contraindicated, the member's psychiatrist must sign a statement specifying the reason for the contraindication and the hospital must maintain the statement in the member's medical and discharge-planning records. (E) Unless clinically contraindicated, the hospital's discharge-planning staff or interdisciplinary review team must contact the member’s family to involve them in planning the member's discharge. To this end, family members must be informed of the discharge options and community resources available to the member and provided with lists of community resources in the area. (F) Each visit to a member or meeting with the family by a member of the discharge-planning staff must be noted in the member's discharge-planning record. The notation must include the date of the meeting, all discharge options discussed, any problems raised and plans for addressing them, all agreements reached with the member, and additional steps required for the discharge-planning staff to prepare the member for discharge. (130 CMR 425.419 Reserved)