Scope of Services

(A) The homeless medical respite provider delivers Medical Respite services to members in a community-based setting that meets the building requirements in 130 CMR 458.404(E). (B) Post-Hospitalization Medical Respite Services. A medical respite provider must have the capacity to provide at least the following service components, which reflect a safe haven service model in a low-demand setting, for members requiring post-hospitalization medical respite services: (1) Screening, Intake, and Admission Services. (a) The medical respite provider must screen potentially eligible members referred by Acute Care Hospitals to confirm eligibility for post-hospitalization medical respite services set forth in 130 CMR 458.403: Eligible Members within two calendar days of the member leaving the acute care hospital using policies and procedures that ensure equitable access for underrepresented, historically marginalized groups and reflect the various identities of populations of people experiencing homelessness. The medical respite provider, through the screening process, must document their determination using their professional judgement that admission into the medical respite is likely to reduce or prevent the need for further acute care. (b) The screening and intake procedures shall reflect low-barrier access to services. (c) The medical respite provider will participate, as appropriate, in member discharge planning with the referring acute care hospital provider, which may include sending a staff person to the acute care hospital to meet the referred member or discussing the member’s health needs with the acute care hospital staff. (d) As part of the admission process, introduce and orient the member to medical respite services and staff, provide a tour of the building, and provide a packet of written materials that includes instructions on how to use amenities available on-site. (e) As part of the admissions process, review with the member the types of services that the member will have access to on-site and off-site in accordance with 130 CMR 458.410, including a review of the medical respite provider’s policy regarding whether members who choose to enroll in hospice while at the medical respite will be allowed to stay at the service location to receive hospice services. (f) Medical respite providers shall utilize a code of resident conduct or behavioral agreement document that describes program policies, including description of prohibited behaviors considered threatening to other residents or staff, and the policies and procedures for early discharge for engaging in such prohibited behavior. (g) Behavioral agreement documents reflecting a low-demand setting service model shall be provided to, reviewed by, and signed by the member within 24 hours of admission, and shall be available to all members throughout their medical respite stay upon request. If a member is unable or unwilling to sign behavioral agreement documents, the medical respite provider shall note in the member’s health record that the behavioral agreement documents were provided and verbally reviewed and the member refused to sign. (2) Assessment Services. The medical respite provider shall conduct needs assessments, periodic reassessments, and daily wellness checks for each member receiving medical respite services, and must document such assessments in the member’s health record. Specifically, the medical respite provider shall: (a) Within 24-hours of admission, conduct an assessment to ensure immediate medical needs are met for the member, including ensuring the availability of needed prescriptions. (b) Within four calendar days of admission, conduct a comprehensive baseline needs assessment to determine factors that will influence care, treatment, safety in the milieu and needed services from the medical respite provider and other community-based providers using standardized and non-standardized measures, as appropriate. The assessment must include, at a minimum: 1. the member’s understanding and knowledge of their health status; 2. current diagnoses, pertinent history, medication history (including allergies and sensitivities), current medications, and current treatments; 3. gender identity and sexual orientation; 4. physical and mental health status; 5. behavioral health needs, including substance use and screening for suicidal and homicidal ideation; 6. active symptoms; 7. fall and overdose risks; 8. screening for health-related social needs; and 9. cultural and language needs and considerations. (c) Conduct a comprehensive housing assessment within the first week of the medical respite stay, including at a minimum: 1. housing history; 2. housing needs and preferences; 3. barriers to obtaining housing such as criminal records, past evictions, and any rental arrears owed; and 4. status of any current housing applications. (d) Conduct a comprehensive needs reassessment with the member as frequently as necessary and in no event less than every 60 days. (e) Conduct at least one wellness check every 24 hours. (3) Care Planning. The provider must complete an individualized care plan for every member receiving medical respite services upon completion of the comprehensive baseline needs assessment and must update the individualized care plan, as necessary, after each comprehensive needs reassessment. Specifically, the individualized care plan must: (a) With input from the member, identify the member’s needs, goals and priorities, and include planned treatments and planned strategies and interventions to support the member’s goals. (b) As appropriate, be developed in consultation with the member and member’s chosen support network, which may include family, and other natural or community supports; (c) As appropriate, be developed by incorporating available records from referring and existing providers and agencies, including any bio-psychosocial assessment, reasons for referral, goals, and discharge recommendations. (d) Be in writing, and include at least the following information, as appropriate to the member’s needs: 1. The member’s identified needs that may be addressed through the provision of medical respite services; 2. The member’s strengths; 3. Clearly defined interventions and measurable goals; 4. Identified interventions, services, and public benefits that the member may be eligible for or entitled to (e.g. SNAP benefits, housing assistance, TANF, etc.) to be coordinated by the provider based on member’s goals and the reason for referral/admission to the medical respite; 5. Supports for self-administration of medications and member progress toward self- management of medications, including plans for optimizing medication adherence, which may include education or identification and provision of supports and adaptations for taking medications; 6. Clearly defined staff responsibilities and assignments for implementing the plan; 7. The date the plan was last reviewed or revised; 8. The signatures of the member, medical respite staff and/or CSP-HI involved in the most recent review or revision; and 9. An initial timeline for the medical respite stay and planning for discharge post- medical respite. (e) Be reviewed and revised at least every 60 days and updated with any significant changes. (4) Case Management Services. The provider must have effective methods to proactively coordinate care and refer members promptly and efficiently to community resources based on the member’s care plan. (a) The medical respite provider must conduct case management services in accordance with written policies and procedures for addressing a member’s physical, behavioral health, social and functional needs. Policies and procedures should minimally address: 1. Coordinating with pre-existing case management and facilitating ongoing case management supports as needed; 2. Identifying barriers to accessing health care and related services; 3. Helping members navigate health systems and establish ongoing relationships with primary care providers and other health care providers; 4. Helping members establish relationships with community behavioral health providers as needed; 5. Supporting members when behavioral concerns arise to maximize retention in the medical respite; 6. Helping members, as appropriate, understand MassHealth hospice service options and any potential changes to medical respite services or ability to remain in the medical respite setting if the member decides to enroll in the hospice program; 7. Coordinating transportation to and from medical appointments and support services; 8. Facilitating member follow up for medical appointments and accompanying the member to medical appointments, when necessary, to aid the member in addressing their conditions and symptoms and advocating for preferences for care; 9. Ensuring communication occurs between medical respite staff and other health care providers to follow up on any changes in the member’s individualized care plan; 10. Providing access to available social support groups, including on-site member groups, health education, and outside support groups (e.g., cancer support, addiction support, religious and spiritual groups, etc.); 11. Facilitating family/caregiver or support system interaction at the direction and preference of the member; 12. Connecting to and engaging with community health workers and peer support services, in accordance with needs and preferences of the member; 13. Actively communicating and coordinating care with MassHealth managed care plans and Community Partners, if applicable; 14. Providing support with MassHealth eligibility and enrollment processes, including, as applicable, supporting the completion of redetermination paperwork or supporting enrollment processes for MassHealth managed care plans or community partners; and 15. Submitting applications for Supplemental Security Income, Social Security Disability Insurance, Supplemental Nutrition Assistance Program, Department of Transitional Assistance, Department of Mental Health, Department of Developmental Services, Massachusetts Rehabilitation Commission, Medicare or other state and federal benefit programs for which the member may be eligible. (b) When referring a member to a non-medical respite provider for services, the medical respite provider must ensure continuity of care, exchange of relevant health information, and avoidance of service duplication. (c) Referrals should result in the member being directly connected to community resources for assistance with housing, employment, recreation, transportation, education, social services, health care, outpatient behavioral health services, and legal services, as applicable. The medical respite provider must document in the member’s health record a written or verbal acknowledgement by the referred entity that includes which of the member’s needs may be met by the referred entity and provides next steps for the member to receive the referred services, if applicable. (5) Health and Referral Navigation. The medical respite provider must conduct health and referral navigation to support the member in receiving the services identified in their individualized care plan. Specifically, the medical respite provider must: (a) Assist with member self-administration of medications, including, as necessary: 1. Assisting with prescription management to fill/refill medications; 2. Safely and securely storing member’s medications; 3. Measuring correct doses, preparing medications, and observing member use; 4. Preparing regular (e.g., weekly or monthly) medication box organizers; 5. Providing medication reminders to members; 6. Coordinating self-administration of medications, such as for injections and eye, ear and topical medications. (b) Connect the member to primary care and community health care providers based on individual needs either off-site or on-site at the medical respite service location. Services delivered on-site at the medical respite service location are limited to those that a member would typically be able to safely receive in a home setting after discharge from a hospital; (c) Assist member with setting up and scheduling appointments with established and new providers, including specialty providers, and transferring health information to providers; (d) Address external barriers to receiving and engaging in services, including requesting needed referrals, navigating intake processes, or supporting the member in responding to delays, needed paperwork, or other barriers to attending appointments or receiving health services; (e) Facilitate member access to obtain durable medical equipment (DME), wound care, oxygen, and incontinence supplies, as needed; (f) Ensure there is space at the medical respite for the member to engage with home- based clinical services (e.g., home health, home nursing care, physical therapy, speech, occupational therapy); (g) Coordinate with home-based clinical services providers scheduled to deliver services to ensure such providers arrive as scheduled and members are at the medical respite service location when such providers arrive; (h) Screen and support the navigation process of accessing services for substance use or mental health programs, as needed; and (i) Coordinating referrals for long-term services and supports, when appropriate. (6) Meal Provision Services. The medical respite provider must provide or arrange for meals for each member seven days per week, as follows: (a) Provide at least three meals per day and snacks. (b) Meal services must meet applicable public health department food handling guidelines. (c) Meal services may include provision of unprepared food for members who are able and prefer to prepare their own meals, if a fully equipped kitchen is available. (d) Kitchens must be kept safe and hygienic, including providing proper refrigeration and trash disposal. (e) Meal services must be culturally appropriate. (7) Intensive Housing Navigation Services. The medical respite provider must coordinate provision of CSP-HI services to each member in accordance with 130 CMR 461.000 Community Support Program Services pursuant to 130 CMR 458.404(D). (a) Referral to the CSP-HI services should occur as soon as possible upon admission, in accordance with the care planning process in 130 CMR 458.410(B)(3) and documented in the medical record. (b) Requirements of Section 2(C)(1)(b) of Guidelines for Medical Necessity Determination for the Community Support Program are waived for members receiving CSP-HI services while residing at a Homeless medical respite service location. Specifically, members do not need to have identified a permanent supportive housing opportunity where they will be moving into housing within 120 days in order to receive CSP-HI services while at the medical respite. (8) Discharge Planning Services. The provider must perform discharge planning services based on the member’s specific circumstances. (a) The medical respite provider’s discharge policy should be consistent with: 1. the low-demand setting approach of a safe haven model that does not require sobriety or compliance with treatment for admission or continued stay; and 2. the behavioral agreement acknowledged by the member at admission in 130 CMR 458.410(B)(1)(e). (b) The medical respite provider must have a discharge planning process that: 1. Engages the member in the discharge planning process to the extent feasible, including informing the member of the discharge policy and procedures; 2. Engages the member’s MassHealth managed care plan and/or community partner, if applicable, in assisting in the transition of care; 3. Arranges for necessary post-discharge support and clinical services, which shall be documented in the member’s health record; 4. Provides members with options for placement after discharge and, within the confines of available resources or options at the time of discharge, makes every effort to discharge the member to a location other than a shelter or unsheltered location and appropriate level of care and environment, and in the event of discharge to a shelter unsheltered location, arranges for post-discharge services and clinical services as required by 130 CMR 458.410(B)(10)(b)(iii); 5. Documents in the member’s medical record all measures taken to avoid discharge to a shelter or unsheltered location, including but not limited to the documentation of all options for discharge offered, and as applicable, any competent refusal of such options; 6. Keeps a record of all discharges in a form approved by MassHealth and submits such information to MassHealth on a quarterly basis in accordance with 130 CMR 458.406(C); 7. Has a discharge policy that addresses non-routine discharge, including but not limited to death, incarceration, leaving against medical advice, or unplanned leaves of absence; and 8. Has a policy on storage of member belongings after discharge, including length of time belongings will be stored and how belongings may be accessed, including for both planned and unplanned discharges. (c) For planned and unplanned discharges, the medical respite provider, in collaboration with its partner CSP-HI provider, must provide a discharge summary to the member and provide the member with opportunity to discuss the discharge information. Discharge instructions must be provided to the member, in writing, so as to be easily understood by the member and include: 1. Written medication list and medication refill information; 2. Health summary list, allergies, and plans for how to respond to indications of a worsening condition; 3. Instructions for accessing relevant resources in the community (e.g., shelters, day centers, transportation, etc.); 4. List of scheduled or needed follow-up appointments and contact information for the member’s medical providers; 5. Special medical instructions (e.g., weight bearing limitations, dietary precautions, wound orders); 6. List of scheduled or needed follow-up appointments, contact information for community case management and related resources, and where to follow up regarding pending applications (e.g., housing navigators, social service agencies); 7. Health care proxy and advance directive information; and 8. If applicable, list of pending housing options, including status of applications and any scheduled or needed follow up appointments. (d) For planned discharges, provide the discharge summary to the member so the summary is available at the time the member is discharged. For unplanned discharges, provide the discharge summary to the member within three business days of the member’s request. (e) The medical respite provider must generate and send a discharge summary from the medical respite clinical team to the member’s primary care provider and MassHealth managed care plan, if applicable, within two business days of discharge. (C) Pre-procedure Colonoscopy Services. A medical respite provider must have the capacity to provide at least the following service components for members needing pre-procedure colonoscopy services. (1) Screening, Intake, and Admission Services: (a) The medical respite provider must screen potential eligible members to confirm eligibility for pre-procedure colonoscopy services set forth in 130 CMR 458.403 using policies and procedures that ensure equitable access for underrepresented, historically marginalized groups and reflect the various identities of populations of people experiencing homelessness. The medical respite provider through the screening process must document their determination that the prospective member meets the eligibility criteria. (b) The medical respite provider shall coordinate the scheduling of the pre-procedure colonoscopy services with the provider conducting the colonoscopy procedure, as needed, to ensure the medical respite provider has the capacity to provide pre-procedure colonoscopy services in accordance with member needs. (c) The medical respite provider must perform admission activities in accordance with 130 CMR 130 458.410(B)(1)(d) through (g). (d) The medical respite provider must ensure the member has a prescription for pre- procedure preparation items and coordinate timely pick-up of prescription items from a pharmacy, as needed. (2) Pre-procedure Support Services. The medical respite provider must provide services and supports to members including: (a) Access to a private, comfortable, and safe environment for pre-procedure preparation activities, including access to a private room or semi-private room for up to 48 hours of admission to the medical respite location and ensure the room is available post-procedure for recovery prior to discharge; (b) Access to a private bathroom with bathroom supplies as needed to maximize comfort during the procedure preparation process; (c) Appropriate fluids and foods (e.g., Jello or popsicles of certain colors) in accordance with instructions from the procedure provider and specified prescription preparation items; (d) Counseling support, cueing, and supervision to members, as desired by the member, to support adherence with fluid intake amounts at time intervals specified in instructions from the colonoscopy procedure provider and prescription preparation items; (e) Coordination of transportation to the colonoscopy procedure and, post-procedure, back to the medical respite; and (f) Provide meal provision post-procedure, as needed. (3) Discharge Planning Services. The provider must perform discharge planning services based on the member’s specific circumstances for discharge and consistent with a safe haven model. Specifically, as part of the discharge planning process, the medical respite provider must: (a) Engage the member to the extent feasible, including informing the member of the discharge policy and procedures; (b) Arrange for necessary post-discharge support and clinical services, which must be documented in the member’s medical record; (c) Provide members with options for placement after discharge from the medical respite setting, and within the confines of available resources or options at the time of discharge, make every effort to transition the member to an acceptable disposition location and appropriate level of care and environment; and (d) Coordinate transportation as part of discharge.