While discharging an adult with a disability to their original home is the first priority, there may be situations in which new housing arrangements must be found. For example, an individual previously living in a group home may not be welcomed back due to the stigma of testing positive for COVID-19. The individual could also require more care post-discharge than can be provided at home due to complications from COVID-19. Conversely, an adult with a disability who was residing in a facility prior to the hospitalization for COVID-19 may be able to discharge to their community with appropriate services and supports. 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… |
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…has limited English proficiency (LEP) | |
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…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 |
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...is blind or vision impaired | - Provide written materials in Braille and/or through spoken word
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...is blind or vision impaired requires LTSS and/or HCBS | - If the individual was receiving HCBS or LTSS before placement in the alternate setting, coordinate with the service provider to ensure that those services can be restarted, either in-person or virtually (if appropriate)
- If the individual is being discharged to a location other than their original home, ensure they can receive the necessary services in their new location
- If the individual requires additional HCBS or LTSS upon discharge, work to establish those services, either in-person or virtually (if appropriate)
- If the individual was previously living in a residential facility such as a nursing home due to LTSS needs, ask them whether they are interested in receiving such services in their community instead.
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...is blind or vision impaired has one or more chronic conditions | |
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...is blind or vision impaired requires nutrition services | |
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...is blind or vision impaired requires infection prevention 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
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Independence
The Individual… | Your discharge planning process should… |
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…has a service animal | - If the individual is being discharged to a location other than their original home, ensure the individual’s new setting allows service animals
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….has mobility devices or assistive technology, or vision and communication needs | - If the individual is being discharged to a location other than their original home, ensure it is accessible based on their specific access and functional needs, including sensory needs. If not, modifications may be necessary.
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Support
The Individual… | Your discharge planning process should… |
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…must be relocated to new housing or an alternate setting such as a step-down facility | - Use Administration for Community Living resources on
living in the community and
public housing for persons with a disability, Administration on Disability resources on
Centers for Independent Living, and your
state’s Medicaid resources to assist the individual in relocating to the most integrated setting possible
- Ensure individuals can be relocated to reconnect with caregivers, support system, and pets (if applicable)
- The individual may experience increased anxiety or other psychological distress when transitioning to an unfamiliar environment. Discuss and plan with the individual and support system the additional behavioral health supports needed
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…has been separated from family or caregivers due to social distancing requirements | |
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Transportation
The Individual… | Your discharge planning process should… |
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…requires transportation home or to their new location | |
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…will require transportation services for groceries, prescriptions, medical appointments, etc. | |
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