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Acute Care Discharge Planning Process Checklist

In an effort to ensure that every effort has been made to access housing resources for homeless members, the Partnership requires documentation in the medical record for each homeless member, which documents the completion of the discharge planning process. This checklist outlines the areas to address in the documentation.

Is there documentation that supports efforts made to contact the member's family and community supports?

Immediate notification to the DMH Homeless Outreach Team (HOT) for all members who are DMH clients:
  • Is the member DMH eligible? If so, contact the HOT Team within two business days.
  • If the member is not a DMH consumer, is there evidence that a DMH eligibility packet was completed and sent to DMH within two days of admission?

Intensive Clinical Management (ICM) referral to the Partnership
  • Was the member considered for an ICM referral?
  • Was an application for ICM services completed and faxed to the Partnership?

Are efforts documented to access those resources listed in the Partnership's Homeless Services Resource List?
  • Is there documentation of each resource contacted?
  • Is there documentation of the result of each contact?

Was additional time in an acute care setting negotiated with the Partnership to ensure a transition to an appropriate discharge setting?

Is the member a veteran?
  • If so, has the Veterans Administration been contacted for potential resources?

Is the member's PCC aware of any current medical conditions which require treatment?

Does the member have a chronic medical condition?
  • If so, has a referral to a nursing home or extended care facility been considered?

Future Partnership chart audits will measure compliance with this Discharge Planning Process

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