The department shall work in partnership with hospitals in assisting patients and their families to find long-term care services of their choice. The department shall not delay hospital discharges but shall assist and support the activities of hospital discharge planners. The department also shall coordinate with home health and hospice agencies whenever appropriate. The role of the department is to assist the hospital and to assist patients and their families in making informed choices by providing information regarding home and community options to individuals who are hospitalized and likely to need long-term care.
(1) To the extent of available funds, the department shall assess individuals who:
(a) Are medicaid clients, medicaid applicants, or eligible for both medicare and medicaid; and
(b) Apply or are likely to apply for admission to a nursing facility.
(2) For individuals who are reasonably expected to become medicaid recipients within one hundred eighty days of admission to a nursing facility, the department shall, to the extent of available funds, offer an assessment and information regarding appropriate in-home and community services.
(3) When the department finds, based on assessment, that the individual prefers and could live appropriately and cost-effectively at home or in some other community-based setting, the department shall:
(a) Advise the individual that an in-home or other community service is appropriate;
(b) Develop, with the individual or the individual's representative, a comprehensive community service plan;
(c) Inform the individual regarding the availability of services that could meet the applicant's needs as set forth in the community service plan and explain the cost to the applicant of the available in-home and community services relative to nursing facility care; and
(d) Discuss and evaluate the need for ongoing involvement with the individual or the individual's representative.
(4) When the department finds, based on assessment, that the individual prefers and needs nursing facility care, the department shall:
(a) Advise the individual that nursing facility care is appropriate and inform the individual of the available nursing facility vacancies;
(b) If appropriate, advise the individual that the stay in the nursing facility may be short term; and
(c) Describe the role of the department in providing nursing facility case management.