This regulation defines the service components and reimbursement requirements for transition planning services in the District of Columbia, which assist individuals being discharged from institutional treatment settings (inpatient or residential) into lower levels of care. Providers must engage in discharge plan development, care coordination, and implementation activities—including assessments, medication reconciliation, linkage to post-discharge services, and ensuring necessary supports are in place. Specific minimum service components are required depending on whether discharge occurs within or after 48 hours of the provider being notified. All Medicaid or local reimbursement claims must include active NPI numbers for both the certified and rendering provider.
View official source6511 TRANSITION PLANNING SERVICE COMPONENTS 6511.1 The transition planning service provides individuals not otherwise connected to care coordination or case management programs with similar support prior to being discharged from certain institutional treatment settings into lower levels of care. The transition planning service connects clients/consumers to treatment and support services that promote their recovery and reduce the chances of avoidable inpatient or residential treatment readmissions. The transition planning service consists of activities related to development of a discharge plan, including assessment of the client’s/consumer’s needs post-discharge, and care coordination and case management related to implementation of the identified needs. Transition planning provider activities, as appropriate and applicable to an individual client/consumer, include, but are not limited to the following: Discharge plan development: Participation in the discharging facility’s discharge planning process and treatment team meetings; Ensuring participation by the client/consumer (and parent or guardian, if applicable) in the discharge planning, and where appropriate, promoting participation by family members and other natural supports; Promoting participation by providers of needed post-discharge services and supports, if already identified; If not already completed, participating in and/or conducting the following activities using a person-centered planning approach: Assessments of clients’/consumers’ strengths and challenges, which, if applicable, shall include use of a Department-approved functional assessment tool; Assessments of needed services and supports, e.g., financial (e.g., Supplemental Security Income), environmental (e.g., housing or transportation), medical (e.g., mental health, SUD, or physical health), social (e.g., legal or educational) and emotional; and For clients/consumers who have been readmitted following a stay within the past thirty (30) calendar days, in depth reviews or case conferences to inform the discharge planning process and reduce readmission risks and increase the likelihood of obtaining appropriate follow-up care; Identifying available resources (e.g., informal, District, or other community resources) to address identified needs; Making recommendations on the discharge plan to the rest of discharge planning team; Meeting with the client/consumer (and/or family/natural supports, when applicable and appropriate) outside of treatment team meetings to collect information relevant to discharge plan development and establish the transition planning provider as a resource; and Ensuring medication reconciliation has been conducted; and Collaborating with the discharging facility on and leading activities related to implementation of the discharge plan, such as: Verification that the client’s/consumer’s insurance covers their medication(s), and that the client/consumer has sufficient medication and prescriptions to bridge the time-period between discharge and a follow-up medication-somatic appointment; Meeting with the client/consumer (and/or family/natural supports, when applicable and appropriate), to: Promote understanding of the discharge plan and discuss the status of implementation; and Provide education regarding diagnoses and what to do in case of post-discharge problems; Working with the client/consumer, and parent or guardian when applicable and appropriate, to select post-discharge service providers, based on the client’s/consumer’s needs; Re-establishing, as appropriate, any pre-existing linkages to providers; Coordinating with the discharging entity to ensure needed health care appointments have been made; and Ensuring necessary supports (e.g., transportation) are in place, making arrangements if necessary, for clients/consumers to transfer to lower levels of care or attend post-discharge appointments; Engaging in care coordination with the health care providers who will be treating the client/consumer post-discharge; Working to ensure that any needed prior authorization(s) for service(s) are in place on the day of the client’s/consumer’s discharge; Coordinating with the discharging entity to assist in acquisition of other needed services and supports, e.g., housing, public benefits; and Ensuring post-discharge providers of treatment and supports receive the relevant discharge plan information. 6511.2 In order to be eligible for reimbursement for rendering a transition planning service, the provider shall meet the following requirements: The transition planning service components are rendered anytime during the thirty (30) calendar days prior to and/or on the day of the client’s/consumer’s discharge from an institutional stay that meets the requirements described in § 6501.2; For clients/consumers who are discharged within forty-eight (48) hours after the transition planning provider is notified of the need for the service, the provider shall at a minimum render the following service components: Participate in the discharging facility’s discharge planning process, including any treatment team meeting(s); Meet with the client/consumer (and/or parent or guardian, when applicable and appropriate), to conduct applicable activities described in §§ 6511.1(a)(7) and 6511.1(b)(2), unless the consumer/client (or parent or guardian) refuses to meet despite having consented to the transition planning service. In such cases the provider shall document the refusal. Any first meeting with the client/consumer shall be in-person, unless not permitted or feasible due to documented, extenuating circumstances; and Conduct implementing activities related to at least one (1) of the needs identified in the discharge plan; and For clients/consumers whose discharge occurs more than forty-eight (48) hours after the transition planning provider is notified of the need for the service, the provider shall at a minimum render the following service components: All components described in § 6511.2(b); and If not already completed, participating in and/or leading completion of: Person-centered assessments of clients’/consumers’ strengths and challenges, which, if applicable, shall include use of a Department-approved functional assessment tool; and Person-centered assessments of needed services and supports, e.g., financial (e.g., Supplemental Security Income), environmental (e.g., housing or transportation), medical (e.g., mental health, SUD, or physical health), social (e.g., legal or educational) and emotional. (d) All claims seeking Medicaid or local only reimbursement under this Chapter shall include the active NPI numbers for the certified provider and the rendering provider. The rendering provider is the staff member who provided the service. SOURCE: Final Rulemaking published at 68 DCR 876 (January 15, 2021); as amended by Final Rulemaking published at 69 DCR 013495 (November 4, 2022). District of Columbia Municipal Regulations Mental Health 22-A DCMR § 6511