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homelessness, as defined by 24 CFR 91.5 except for the annual income requirement in 24 CFR 91.5 (1)(i). It also targets those at risk of hospitalization or readmission requiring post-discharge support, pre-procedure preparation, or ongoing treatment for conditions such as chemotherapy. Eligible individuals must be independently mobile, able to perform ADLs and have a primary medical diagnosis to ensure alignment with the program's goals of stabilizing health and reducing preventable hospitalizations.

Process for Identifying Medical Necessity for Recuperative Care Pilot Services The TEAMKY Recuperative Care Pilot employs a structured, comprehensive process to identify medical necessity and ensure services are aligned with the health and social needs of eligible individuals. Medical necessity is assessed upon referral, during admission, and throughout the individual’s stay, using clearly defined criteria and evidence-based practices. This approach ensures that care is targeted, appropriate, and effectively meets the requirements of Medicaid- eligible individuals who are experiencing or at risk of homelessness. Upon referral to a recuperative care program, an individual undergoes an eligibility screening to determine if they meet the core criteria: being at risk of or experiencing homelessness (as defined by 24 CFR 91.5), having a primary medical diagnosis, and facing hospitalization or readmission risks with specific aftercare needs. Examples of qualifying needs include post-acute discharge care, pre-procedure preparation, or episodic treatment such as chemotherapy. Additionally, the individual must be aged 18 or older, independently mobile (with or without assistive devices), and capable of performing basic ADLs. Once admitted to the program, a detailed nursing assessment is conducted within 24 hours by a licensed clinical professional with a minimum qualification of a Registered Nurse. This assessment involves a comprehensive review of the individual’s discharge instructions, vitals, living situation, patient and mental status, impairments, medication reconciliation, ADLs, and elimination needs. The findings of this assessment inform the development of a personalized care plan, ensuring alignment with the patient’s medical, behavioral, and social requirements. Daily evaluations are integral to monitoring and validating the ongoing medical necessity of services. Registered nurses perform daily wellness checks that include vital assessments, pain management, care plan reviews, and progress tracking. These evaluations assess compliance with treatment, participation in self-care, and any changes in condition that may require adjustments to the care plan. A key component of these checks is medication monitoring, which includes ensuring access to prescribed medications, educating patients on self-administration, and fostering independence in medication management. Behavioral health services, when identified as medically necessary, are incorporated into the care plan. Licensed behavioral health practitioners provide screenings, brief interventions, and referrals to community-based services as needed. Care coordination further supports the process by addressing social determinants of health (SDOH) and ensuring the integration of medical, behavioral, and social services. A care coordination plan is established within 72 hours of