Person-Centered Hospital Discharge Model

The Person-centered Hospital Discharge Model grant built upon the RCSC and Aging and Disability Resource Center (ADRC) grant opportunities by providing targeted assistance to States to improve hospital discharge planning through collaboration with ADRCs and Area Agencies on Aging and Centers for Independent Living. In 2008 and 2009, $12.4 million in grant money was awarded to ten States. This HDM grant opportunity is designed to:

  1. Promote the development and implementation of enhanced hospital discharge planning models that meaningfully engage Medicaid-eligible individuals with disabilities (and their informal caregivers);
  2. Increase the capacity of existing, and develop new, single entry points (including ADRCs) to provide critical linkages to available long-term care services in the community and much needed supports for informal caregivers themselves;
  3. Inform CMS, other Federal agencies and Congress on national policy related to hospital discharge planning, Person-centered planning, and caregiver assessment.

State specific models

Alaska Person Centered Hospital Discharge Planning Model

Idaho Person Centered Hospital Discharge Planning Model

Kansas Person Centered Hospital Discharge Planning Model

Missouri Person Centered Hospital Discharge Planning Model

Oregon Person Centered Hospital Discharge Planning Model

South Carolina Person Centered Hospital Discharge Planning Model

Grantee Accomplishments

The 2008 grantees have requested extensions to continue implementation through September 2012. The 2009 grantees are actively engaged in implementation and testing of the models. All grant activities should be completed by September 2012. The following accomplishments have been achieved by many of the grantees as they move into their phases of implementation:

  • Built effective and inclusive stakeholder partnerships and collaborations;
  • Initiated and maintained interagency collaborative that have a direct impact on infrastructure and systematic changes within the States’ long-term care system;
  • Identified and implemented a Hospital Discharge Planning Model (such as the Coleman, RED, BOOST, or GRACE models) that is cohesive and comprehensive for the individuals that are assisted in their discharge planning which subsequently helps to decrease the now mandated decrease in hospitals readmissions; and
  • Increased in the development and enhancement of over 170 ADRCs across the nation.
  • Increased the capacity of existing, and develop new, single entry points (including ADRCs) to provide critical linkages to available long-term care services in the community and much needed supports for informal caregivers themselves; Inform CMS, other Federal agencies and Congress on national policy related to hospital discharge planning, Person-centered planning, and caregiver assessment.