New Housing

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…
…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
...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. If they would like to receive LTSS in a home or community-based setting, work to establish those services, either in-person or virtually, and to connect the individual to appropriate resources to acquire housing. For assistance in establishing these services, see the Aging and Disability Resource Centers (ADRCs) / No Wrong Door System
...is blind or vision impaired 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.
...is blind or vision impaired 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
...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

Independence

The Individual…	Your discharge planning process should…
…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
….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. For an assessment to address functional needs, see the State Grant for Assistive Technology (AT) Programs

Support

The Individual…	Your discharge planning process should…
…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 HUD may also be a resource, but is beyond the scope of this resource. Please visit the HUD webpage for individuals with disabilities for further information For further assistance, see the Aging and Disability Resource Centers (ADRCs) / No Wrong Door System 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
…has been separated from family or caregivers 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. If visitation is allowed, ensure the individual has opportunities to see their family or caregivers in a manner consistent with infection prevention measures If visitation is not allowed, provide technology and technological assistance (if needed) to facilitate virtual visits For social programs and technologies, see the Aging and Disability Resource Centers (ADRCs) / No Wrong Door System Under Sec 3715 of the CARES Act, an individual’s personal aides may accompany them to hospitals. For more information see page 39 of COVID-19 Frequently Asked Questions (FAQs) for State Medicaid and Children’s Health Insurance Program (CHIP) Agencies

The Individual…

Your discharge planning process should…

…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

HUD may also be a resource, but is beyond the scope of this resource. Please visit the HUD webpage for individuals with disabilities for further information
For further assistance, see the Aging and Disability Resource Centers (ADRCs) / No Wrong Door System

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

…has been separated from family or caregivers 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. If visitation is allowed, ensure the individual has opportunities to see their family or caregivers in a manner consistent with infection prevention measures
If visitation is not allowed, provide technology and technological assistance (if needed) to facilitate virtual visits

For social programs and technologies, see the Aging and Disability Resource Centers (ADRCs) / No Wrong Door System

Under Sec 3715 of the CARES Act, an individual’s personal aides may accompany them to hospitals. For more information see page 39 of COVID-19 Frequently Asked Questions (FAQs) for State Medicaid and Children’s Health Insurance Program (CHIP) Agencies

Transportation

The Individual…	Your discharge planning process should…
…requires transportation home or to their new location	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.
…will require 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