Arizona Department of Health ServicesEffective Date: XX/xx/xxxx
Division of Behavioral Health ServicesLast Review Date: xx/xx/xxxx
Policy and Procedures Manual
SECTION XX, CHAPTER XX
POLICY XX, DISCHARGE PLANNING
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1. PURPOSE:
Regional Behavioral Health Authority (RBHA) enrolled persons receiving inpatient services must have proactive discharge planning that identifies and assesses post-discharge clinical and social needs in order to arrange necessary services and resources for appropriate and timely discharge from a facility.
The intent of this policy is to outline requirements for improving the coordination of post discharge services, reducing unnecessary stays, increasing the management of inpatient admissions and decreasing unplanned or emergency readmissions within 30 days of discharge.
2. TERMS:
Definitions for terms are located online at http://www.azdhs.gov/bhs/definitions/index.php The following terms are referenced in this section:
Durable Medical Equipment (DME)
Sturdy, long lasting and reusable items and appliances used at home prescribed by a licensed physician or other authorized licensed medical professional such as physician assistant, nurse practitioner, clinical nurse specialist, necessary to address a medical or physical need, and must not ordinarily be used in the absence of a medical or physical condition.
Health Care Professional
Physician, podiatrist, optometrist, chiropractor, psychologist, dentist, physician assistant, physical or occupational therapist, speech-language pathologist, audiologist, registered or practical nurse (including nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist and certified nurse midwife), licensed social worker, registered respiratory therapist, licensed marriage and family therapist and licensed professional counselor.
Inpatient Services
Services provided in hospitals and inpatient behavioral health facilities (see 9 A.A.C. 10).
Nursing Facility
For the purposes of this policy, a Nursing Facility is a health care institution licensed to operate using the AHCCCS provider type 22 “Nursing Home”
Primary Care Physician
An individual who meets the requirements of A.R.S. § 36-2901, and who is responsible for the management of the member's health care. A PCP may be a physician defined as a person licensed as an allopathic or osteopathic physician according to A.R.S. Title 32, Chapter 13 or Chapter 17, or a practitioner defined as a physician assistant licensed under A.R.S. Title 32, Chapter 25, or a nurse practitioner licensed under A.R.S. Title 32, Chapter 15. The PCP must be an individual, not a group or association of persons, such as a clinic.
Title XIX Eligible Person
An individual who meets Federal and State requirements for Title XIX eligibility.
Title XXI Eligible Person
An individual who meets federal and state requirements for Title XXI eligibility.
PROCEDURES:
The RBHA must develop and implement a discharge planning process to address the post-discharge clinical and social needs of the member upon discharge. The process shall be initiated by a qualified health care professional as soon as possible before, upon or immediately after admission and updated periodically during the inpatient admission to ensure accurately determined continuing care needs. The discharge plan must be appropriately documented in the person’s medical record and must be completed before discharge occurs. The RBHA must ensure that its subcontracted providers have a process that includes:
a. Proactive discharge assessment by qualified healthcare professionals identifying and assessing the specific post discharge bio-psychosocial and medical needs of the eligible person prior to discharge. This process shall include the involvement and participation of the eligible person and representative(s), as applicable. The person and representative(s), as applicable, must be provided with the written discharge plan with instructions and recommendations identifying resources, referrals and possible interventions to meet the person’s assessed and anticipated needs after discharge.
b. The coordination and management of the care that the eligible person receives following discharge from an acute setting. This may include:
i Providing appropriate post discharge community referrals and resources or scheduling follow up appointments with the person’s primary care provider and/or other outpatient healthcare providers within 7 days of discharge.
ii Coordination of care involving effective communication of the eligible person’s treatment plan and medical history across the various outpatient providers to ensure that the member receives medically-necessary services that are both timely and safe after discharge.
iii Coordination with the member’s outpatient clinical team to explore interventions to address the member’s needs such as case management, disease management, placement options, and community support services.
c. Access to prescribed discharge medications.
d. Post discharge follow-up contact to assess the progress of the discharge plan according to the member’s assessed clinical and social needs.
e. Access to Durable Medical Equipment (DME).
f. A discharge plan that is documented in the member’s medical record.
REPORTING:
The RBHAs must develop a process to audit discharge plans that includes determining and applying a minimum performance score for compliance with this policy. RBHAs are expected to report as a standing agenda item within the appropriate committee, the outcomes of such audits with plans for corrections when discharge planning standards as set forth by the RBHA are not met. RBHA discharge plan audits will be subject to monitoring and oversight by ADHS.
3. REFERENCES:
AHCCCS/ADHS Contract
ADHS/RBHA Contracts
AHCCCS Medical and Policy Manual (AMPM) Chapter 1000, Policy 1020, Section C
4. APPROVED BY:
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Cory Nelson, MPA Date
Deputy Director
Arizona Department of Health Services
Division of Behavioral Health Services
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Steven Dingle M.D. Date
Medical Director
Arizona Department of Health Services
Division of Behavioral Health Services
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XX.X Discharge Planning
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