(1) The medical respite program will discharge the client when the client meets one of the following:
(a) No longer benefits from medical respite care services;
(b) Reaches the 90-day utilization limit for their current admission or the six-month utilization during the demonstration period; or
(c) An appropriate alternative service becomes available.
(2) The six-month utilization period limit is shared amongst other housing support services including, but not limited to, housing transition navigation services, and rent/temporary housing.
(3) The medical respite program must begin discharge planning upon the client's admission and maintain discharge planning throughout the client's stay at the facility.
(4) To discharge a client, the program must provide a referral tailored to client needs, to include:
(a) Potential housing options;
(b) Referrals to appropriate health care providers;
(c) Supportive services; and
(d) Provide advance and written notice of discharge to the client, and as applicable, the client's health care provider, managed care organization, and caregivers.
(5) Upon admission and discharge, the program must provide an admission or discharge summary to the client, the health care provider, the managed care organization if applicable, and other persons or entities requested by the client. The admission or discharge summary must include the following:
(a) Written medication list and medication refill information;
(b) Admitting primary diagnosis following discharge from the hospital or referral from a medical clinic;
(c) Estimated or documented length of stay in the medical respite program;
(d) Ongoing medical needs or conditions;
(e) Instructions for accessing relevant resources within the community including shelters or other housing options;
(f) A list of follow-up appointments and contact information for treating providers;
(g) Special medical instructions (e.g., weight-bearing limitations, dietary precautions, allergies, wound orders);
(h) Pain management plan; and
(i) A point of contact for the client.
(6) The medical respite program must ensure adequate protocols are in place for the transfer of client information and access to electronic records to appropriate providers and, if applicable, the client's managed care organization.