2508

2508.1

Comprehensive Transitional Care includes the Health Home's efforts to reduce hospital emergency department and inpatient admissions, readmissions and length of stay through planned and coordinated transitions between health care providers locations, settings and levels of care. Health Homes will increase individual's and family members' ability to manage care and live safely in the community, shifting the use of reactive or emergency care and treatment to proactive health promotion and self-management. Comprehensive Transitional Care includes, but is not limited to:

1. (a) Contact with the consumer within forty-eight (48) hours of the completed transition from inpatient settings and ER visits;
2. (b) Outreach to consumers to ensure appropriate follow-up after transitions;
3. (c) Ensuring visits for consumers with the appropriate health and community-based service providers following the completed transition;
4. (d) Developing strategies and supportive health interventions that reduce the risk for or prevent out-of-home placements for adults and builds stronger family support skills and knowledge of the adult's strengths and limitations;
5. (e) Developing chronic health prevention and illness management strategies and plans;
6. (f) Reviewing the discharge summary and instructions;
7. (g) Ensuring that medication reconciliation has been completed;
8. (h) Ensuring that follow-up appointments and tests are scheduled and coordinated;
9. (i) Assessing the patient's risk status for readmission or other failure to obtain appropriate community-based care;
10. (j) Arranging for follow-up care, if indicated in the discharge plan;
11. (k) Planning for appropriate clinical care post-discharge, including home health services or other necessary skilled care;
12. (l) Planning for appropriate housing support services post-discharge, including facilitating linkages to temporary or permanent housing;

(m) Arranging transportation for transitional care and follow-up appointments as needed;

(n) Scheduling appointments for the beneficiary with a primary care provider or appropriate specialist(s) within one (1) week of discharge; and

(o) Opting out of the Health Home Program.

SOURCE: Final Rulemaking published at 63 DCR 849 (January 22, 2016); as amended by Final Rulemaking published at 66 DCR 5625 (May 3, 2019).