When the member's OKDHS social worker, ADvantage case manager, or the AA is informed (by the member, family or service provider) of a member's hospitalization or placement in a nursing facility, that party determines the date of the member's institutionalization and communicates the date, name of the institution, reason for placement and expected duration for placement, to the other ADvantage Program Administrative partners. If a member requires hospital or nursing facility services, the case manager assists the member in accessing institutional care, periodically monitors the member's progress during the institutional stay and, as appropriate, updates the service plan and prepares services to start on the date the member is discharged from the institution and returns home. All case management units for "institution transition" services to plan for and coordinate service delivery and to assist the member to safely return home, even if provided while the person is in an institution, are to be considered delivered on and billed for the date the member returns home from institutional care.
(1) Hospital discharge. When the member returns home from a hospital or when notified of the member's anticipated discharge date, the case manager notifies relevant providers and the AA and coordinates the resumption of services.
(2) NF placement of less than 30 days. When the member returns home from a NF stay of 30 days or less or when notified of the member's anticipated discharge date the case manager notifies relevant providers, the member's OKDHS worker and the AA of the discharge and coordinates the resumption of ADvantage services in the home.
(3) NF placement greater than 30 days. When the member is scheduled to be discharged and return home from a NF stay that is greater than 30 days, the member's OKDHS worker, ADvantage case manager, or the AA (whoever first receives notification of the discharge), notifies other ADvantage Program Administrative partners to expedite the restart of ADvantage services for the member. In these circumstances, the SPEED process may be used to re-establish ADvantage eligibility to coincide with the date of discharge from the NF. The member's case manager provides "institution transition" case management services to assist the member to re-establish him or herself safely in the home.