Care-coordination activities are especially important to reconnect persons with disabilities to their communities when they are discharged after a COVID-19 related hospitalization, isolation, or quarantine. Ensuring that persons with disabilities have meaningful access to community life requires nurses, medical social workers, case managers, and other discharge professionals to overcome additional obstacles presented by the public health emergency including limited staff, support services, and the changing needs of persons with disabilities who are recovering from COVID-19.
The HHS Office of the Assistant Secretary for Preparedness and Response in partnership with the HHS Centers for Medicare and Medicaid Services and the HHS Administration for Community Living developed the Discharge Planning and Care Coordination tool to address discharge planning during an emergency.
Throughout the discharge process, care coordinators need to remember to put the needs of the patient first. In order to translate this somewhat broad concept into an actionable plan, the Discharge Planning and Care Coordination tool takes a person-centered approach to planning and leverages the CMIST Framework (Communication, Maintaining Health, Independence, Support, and Transportation) to help providers find discharge solutions.
While a framework to guide discharge planning decisions is helpful, there is no one-size-fits-all solution. Providers need to take a person-centered approach and work with the patient to determine what he or she wants their post-discharge environment to look like. Working together, the patient and the provider should develop a plan to optimize the patient’s quality of life, taking into account his or her preferences, needs, and wants. The goal of person-centered planning is to create a plan that would accommodate the person’s self-defined quality of life, choice, control, and self-determination.
The CMIST Framework outlines the considerations required to select the most appropriate discharge setting from a multidisciplinary perspective. The resource takes a comprehensive approach to discharge planning and assists planners as they identify the most appropriate settings for persons with disabilities after a COVID-19 diagnosis and during an active public health emergency.
Journey Map for COVID-19 Positive Individuals with Disabilities Who Live in Community-Based Settings
Depending on their disability-related needs and COVID-19 recovery, people with disabilities may be discharged to three common settings: home, temporary care (nursing homes or swing bed hospital), or new housing.
While a return home is preferable and may be appropriate for those who have tested negative for COVID-19, some persons with disabilities require additional services found in a more supportive living environment as they recover from a COVID-19–related illness. A decline in health related to the COVID-19 diagnosis or loss of community support services due to the emergency may necessitate the reevaluation of living arrangements and support services. Others may find that they are able to transition to a more independent community setting upon release from the hospital.
The tool includes a number of planning resources for professionals, such as a journey map and resources detailing national and state programs and federal contracts that support care coordination activities.
Right now, nurses, medical social workers, case managers, and other discharge professionals are facing tough decisions every time COVID-19 patients are discharged. Ultimately, the goal is to empower persons with disabilities to return to a setting that is as independent and integrated as possible when it is safe to do so after a COVID-19 diagnosis. Using a standardized framework, to make more informed decisions can help people with disabilities receive appropriate care while still protecting clinicians, staff and others. To get started, check out the Discharge Planning and Care Coordination during the COVID-19 Pandemic.