23-660 Hospital and Inpatient Facility Discharge Planning and Notification
Support seamless care transitions with discharge summary and medication lists
Participating hospitals and inpatient facilities (general acute care hospitals, long-term acute care hospitals and skilled nursing facilities) are required to comply with applicable Health Net policies and procedures for discharge planning and care transition protocols. Hospitals and inpatient facilities should have established discharge and care transition protocols in place when transitioning members from inpatient facilities to their homes and other community-based settings to support effective care transitions.
Additional information on discharge planning and care transition protocols, including discharge notification is available online under Provider Resources > Manuals, Forms and Resources > Provider Manual/Billing Manual – English (PDF).
Discharge notification to PCP and ECM providers
To improve continuity and coordination of care for members and support seamless care transitions, hospitals and inpatient facilities must notify and communicate with the member’s primary care physician (PCP) and Enhanced Care Management (ECM) provider within 24 hours of discharge from a hospital or inpatient facility.
When notifying the member’s PCP and ECM provider of a discharge, provide the information below:
- Member name
- Identification (ID) number from patient’s membership ID card
- Date of birth (DOB)
- Admission and discharge dates
- Attending physician name
- Attending physician phone number
- Follow-up appointment date, if known
- Discharge destination
- Responsible party at discharge
- Level of assistance required
- Discharge planning needs including equipment, service or other special training needs
- Medications, including dosage and frequency at discharge
- Facility name and phone number
How to identify the member’s PCP and ECM provider
Refer to the member’s California Health & Wellness Plan (CHWP) ID card to identify the member’s PCP. The PCP’s name, address and phone number are noted on the back of the ID card. If the PCP is affiliated with an independent practice association (IPA), the IPA’s name and phone number will also be listed on the back of the card.
Identifying ECM provider
- Log into the secure provider portal at www.CAHealthWellness.com.
- Select Eligibility and search eligibility for the member.
- Select Enhanced Care Management on the left navigation.
Relevant sections of the provider operations manuals have been revised to reflect the information contained in this update as applicable. The provider operations manual is available in the Provider Resources section of the provider website.
Providers are encouraged to access CHWP’s provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CHWP at 877-658-0305.
This Information applies to Independent Practice Associations (IPAs), Hospitals, and Ancillary Providers.