D.C. Mun. Regs. tit. 22, r. 22-A6511

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 22-A6511 - TRANSITION PLANNING SERVICE COMPONENTS

6511.1

The transition planning service provides individuals not otherwise connected to care coordination or case management programs with similar support prior to being discharged from certain institutional treatment settings into lower levels of care. The transition planning service connects clients/consumers to treatment and support services that promote their recovery and reduce the chances of avoidable inpatient or residential treatment readmissions. The transition planning service consists of activities related to development of a discharge plan, including assessment of the client's/consumer's needs post-discharge, and care coordination and case management related to implementation of the identified needs. Transition planning provider activities, as appropriate and applicable to an individual client/consumer, include, but are not limited to the following:

(a) Discharge plan development:

(1) Participation in the discharging facility's discharge planning process and treatment team meetings;

(2) Ensuring participation by the client/consumer (and parent or guardian, if applicable) in the discharge planning, and where appropriate, promoting participation by family members and other natural supports;

(3) Promoting participation by providers of needed post-discharge services and supports, if already identified;

(4) If not already completed, participating in and/or conducting the following activities using a person-centered planning approach:

Assessments of clients'/consumers' strengths and challenges, which, if applicable, shall include use of a Department-approved functional assessment tool;

ii.

Assessments of needed services and supports, e.g., financial (e.g., Supplemental Security Income), environmental (e.g., housing or transportation), medical (e.g., mental health, SUD, or physical health), social (e.g., legal or educational) and emotional; and

iii.

For clients/consumers who have been readmitted following a stay within the past thirty (30) calendar days, in depth reviews or case conferences to inform the discharge planning process and reduce readmission risks and increase the likelihood of obtaining appropriate follow-up care;

(5) Identifying available resources (e.g., informal, District, or other community resources) to address identified needs;

(6) Making recommendations on the discharge plan to the rest of discharge planning team;

(7) Meeting with the client/consumer(and/or family/natural supports, when applicable and appropriate) outside of treatment team meetings to collect information relevant to discharge plan development and establish the transition planning provider as a resource; and

(8) Ensuring medication reconciliation has been conducted; and

(b) Collaborating with the discharging facility on and leading activities related to implementation of the discharge plan, such as:

(1) Verification that the client's/consumer's insurance covers their medication(s), and that the client/consumer has sufficient medication and prescriptions to bridge the time-period between discharge and a follow-up medication-somatic appointment ;

(2) Meeting with the client/consumer (and/or family/natural supports, when applicable and appropriate), to:

Promote understanding of the discharge plan and discuss the status of implementation; and

ii.

Provide education regarding diagnoses and what to do in case of post-discharge problems;

(3) Working with the client/consumer, and parent or guardian when applicable and appropriate, to select post-discharge service providers, based on the client's/consumer's needs;

(4) Re -establishing, as appropriate, any pre-existing linkages to providers;

(5) Coordinating with the discharging entity to ensure needed health care appointments have been made; and

(6) Ensuring necessary supports (e.g., transportation) are in place, making arrangements if necessary, for clients/consumers to transfer to lower levels of care or attend post-discharge appointments;

(7) Engaging in care coordination with the health care providers who will be treating the client/consumer post-discharge ;

(8) Working to ensure that any needed prior authorization(s) for service(s) are in place on the day of the client's/consumer's discharge;

(9) Coordinating with the discharging entity to assist in acquisition of other needed services and supports, e.g., housing, public benefits; and

(10) Ensuringpost-discharge providers of treatment and supports receive the relevant discharge plan information.

6511.2

In order to be eligible for reimbursement for rendering a transition planning service, the provider shall meet the following requirements:

(a) The transition planning service components are rendered anytime during the thirty (30) calendar days prior to and/or on the day of the client's/consumer's discharge from an institutional stay that meets the requirements described in § 6501.2;

(b) For clients/consumers who are discharged within forty-eight (48) hours after the transition planning provider is notified of the need for the service, the provider shall at a minimum render the following service components :

(1) Participate in the discharging facility's discharge planning process, including any treatment team meeting(s);

(2) Meet with the client/consumer (and/orparent or guardian, when applicable and appropriate), to conduct applicable activities described in §§ 6511.1(a)(7) and 6511.1(b)(2), unless the consumer/client (or parent or guardian) refuses to meet despite having consented to the transition planning service. In such cases the provider shall document the refusal. Any first meeting with the client/consumer shall be in-person, unless not permitted or feasible due to documented, extenuating circumstances; and

(3) Conduct implementing activities related to at least one (1) of the needs identified in the discharge plan; and

(c) For clients/consumers whose discharge occurs more than forty-eight (48) hours after the transition planning provider is notified of the need for the service, the provider shall at a minimum render the following service components:

(1) All components described in § 6511.2(b); and

(2) If not already completed, participating in and/or leading completion of:

Person-centered assessments of clients'/consumers' strengths and challenges, which, if applicable, shall include use of a Department-approved functional assessment tool; and

ii.

Person-centered assessments of needed services and supports, e.g., financial (e.g., Supplemental Security Income), environmental (e.g., housing or transportation), medical (e.g., mental health, SUD, or physical health), social (e.g., legal or educational) and emotional.

(d) All claims seeking Medicaid or local only reimbursement under this Chapter shall include the active NPI numbers for the certified provider and the rendering provider. The rendering provider is the staff member who provided the service.

D.C. Mun. Regs. tit. 22, r. 22-A6511

Final Rulemaking published at 68 DCR 876 (1/15/2021); amended by Final Rulemaking published at 69 DCR 13495 (11/4/2022)