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U.S. Department of Health and Human Services

Returning Home

When discharging an adult with a disability from the acute care setting in which they received treatment or were quarantined for COVID-19 illness, implementing the CMIST Framework using person-centered principles can help you facilitate the individual’s return home to the most integrated setting of their choice. Examples of promising practices for person-centered discharge planning using the CMIST Framework are outlined in the table below. This is not an exhaustive list of care coordination practices. It is unlikely that every consideration described below will apply to an individual’s discharge plan. For individuals with intellectual and developmental disabilities who use decision-making supports, the discharge planning process should include input from their support system.


Communication

The Individual…

Your discharge planning process should…

…has limited English proficiency (LEP)

…is deaf, hard of hearing, or is unable to fully use verbal speech.

  • Provide an ASL translator, either in-person or virtually
  • Have written materials to convey necessary information in plain language or use two-way texting devices
  • If other auxiliary speech or hearing devices, such as hearing aids, are needed, ensure the individual has access to functioning devices
  •  Acquire specialty PPE (if needed) such as clear face masks to facilitate lip reading

...is blind or vision impaired

  • Provide written materials in Braille and/or through spoken word


Maintaining Health

The Individual…

Your discharge planning process should…

…requires LTSS and/or HCBS

  • If the individual was already receiving HCBS or LTSS prior to admission to the hospital, ensure that they are still able to receive these services in-person when they return home
    • If not, can they transition to virtual services, or do they need another form of assistance?
  • If the individual needs HCBS or LTSS, work to establish those services, either in-person or virtually

…has one or more chronic conditions

…requires nutrition services

…requires infection prevention and control measures

  • Facilitate access to PPE for both the individual and direct service workers (DSWs; if applicable) to reduce the risk of infection
  • Provide regular screening for COVID-19, and testing for the individual and DSWs (if appropriate)
  • If the individual is discharged while still COVID+ follow the CDC Guidance on Disposition of Patients with SARS-CoV-2 Infection


Independence

The Individual…

Your discharge planning process should…

…has a service animal

…requires DME


Support

The Individual…

Your discharge planning process should…

…has been separated from family or support providers due to social distancing requirements

  • The individual may experience increased anxiety or other psychological distress and therefore need additional behavioral health supports that are delivered in an accessible, culturally competent manner


Transportation

The Individual…

Your discharge planning process should…

…requires transportation services for groceries, prescriptions, medical appointments, etc.

 

 

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  • This page last reviewed: August 27, 2020