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)	Provide a translator to facilitate appropriate person-centered planning, either in-person or virtually Have written materials in multiple languages that convey necessary information in plain language For additional guidance on addressing LEP, please see Ensuring Language Access and Effective Communication during Response and Recovery: A Checklist for Emergency Responders
…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 For assistance obtaining technology, see the State Grant for Assistive Technology (AT) Programs 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 For assistance in establishing these services, see the Aging and Disability Resource Centers (ADRCs) / No Wrong Door System, or your established local referral source.
…has one or more chronic conditions	Ensure they have access to appropriate medications or other therapeutics, including DME, as individuals with underlying chronic conditions are at increased risk for severe illness from COVID-19.
…requires nutrition services	Connect them with programs for home-delivered meals and/or groceries. For examples of programs, please see Information on Federal Programs to Sustain Nutrition for At-risk Individuals
…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	Ensure the service animal remains with the individual throughout the discharge process and upon returning home. For more information on accommodating service animals, please see Understanding How to Accommodate Service Animals in Healthcare Facilities
…requires DME	Ensure the individual has access to any necessary mobility devices, such as wheelchairs or walkers, and other DME For an assessment to address functional needs, see the State Grant for Assistive Technology (AT) Programs

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 For social programs and technologies, see the Aging and Disability Resource Centers (ADRCs) / No Wrong Door System, or other local coordinating entity.

Transportation

The Individual…	Your discharge planning process should…
…requires transportation services for groceries, prescriptions, medical appointments, etc.	Connect the individual to transportation services that support their independence such as accommodations for DME, mobility devices, or service animals To connect with transportation services, see the Aging and Disability Resource Centers (ADRCs) / No Wrong Door System, or other local coordinating entity.

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Discharge Planning and Care Coordination during COVID-19

This page last reviewed: August 27, 2020