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Office of Mental Health

Home and Community Based Services Waiver
Guidance Document
Division of Children and Families


HCBS Waiver Discharge and Aftercare Plans


Discharge planning begins when the child is first enrolled in the HCBS Waiver. The treatment team, child and family discuss what changes would need to occur for the child to be discharged to a less intense level of care. To accomplish this, relevant goals and services are agreed upon. The family and child are engaged in conversations periodically, as well as at service plan reviews, addressing the child’s progression and probable services needed after discharge from the Waiver. These are recorded in the Progress Notes and in the 90 Day Service Plan Reviews. When discharge is imminent, all elements on the Waiver Discharge Plan and necessary signatures are obtained. The ICC is responsible for all documentation and for coordinating aftercare services. The ICC uses components of the HCBS Waiver Aftercare Follow-Up Plan to document follow-up activities.  At a minimum, the ICC agency is required to contact the family to assure that discharge services are operative and to summarize the child and family’s status at the first two week and four week intervals. The ICC intervenes as appropriate if problems are noted and continues documenting on a Aftercare Follow-Up Plan.

The HCBS Waiver Discharge Plan

The ICC completes the HCBS Waiver Discharge Plan prior to the disenrollment which, in the first section, summarizes the movement of the child and family through the Waiver enrollment period and portrays how discharge readiness has been reached. Included in this brief narrative is a description of the services the child and family have received and progression towards specific, identified goals. The second section lists services, with contact names and numbers, to which the child has been discharged. The third section tracks the completion of all required steps and the fourth section documents supervisory review and child/family agreement.

The HCBS Waiver Aftercare Plan

The HCBS Waiver Aftercare Plan is used by the ICC to document discharge follow-up to ascertain that discharge services are implemented, and if not, what actions need to be taken. It also gives the ICC the opportunity to assess the effectiveness of the discharge plan and to make changes as indicated. This must be completed two weeks and four weeks after discharge and is reviewed by the ICC Supervisor. Follow-up is initiated and documented as needed thereafter.

Sample forms can be found in the HCBS Waiver Guidance Document, Section 800.