Specifications include, but are not limited to: Individuals with complex care needs are increasingly remaining hospitalized in acute care facilities despite no longer having acute healthcare needs. Complex care is defined as individuals with intense needs including mental health, substance use disorder, physical and/or developmental disabilities, etc., which make placement in the community or skilled nursing facilities highly challenging. When these individuals remain in acute care beds it prevents the individual from receiving appropriate care for ongoing chronic and other health needs, limits their personal freedoms, and reduces the number of available acute care beds at hospitals. The purpose of this request is to pilot a program of enhanced discharge planning for individuals with complex care needs, regardless of the individual’s payer source. The chosen contractor(s) will be funded to hire an additional discharge planner whose sole responsibility will be to support the needs of complex care individuals who are currently stuck in acute care beds and need extensive discharge planning to move back to the community, when appropriate, or to a skilled nursing facility. The discharge planners hired under this request will receive support and training from the Money Follows the Person (MFP) Transition Coordinators to increase their community placement, community relationship building, and other referral skills for complex care individuals. At the conclusion of the contract period, contractors will be expected to demonstrate their ability to continue to provide complex care discharge planning through the production of training materials, protocols, and standard procedures that are organized to be transferable to new hospital staff.
