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TEAMKY Demonstration

Approval Period: January 1, 2025 through December 31, 2029

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Components of Short-Term Pre-Procedure and Post-Transition Housing Services The following are components within the Short-Term Pre-Procedure and Post-Transition Housing.  Nursing Services  Nursing assessment within 24 hours of admission.  Daily wellness check conducted by licensed clinical staff (minimum RN).  Assessment of medical stability and ability to participate in care planning and self- care management.  Medication Monitoring  Safe and secure medication storage (preferably double-locked).  Medication reconciliation to ensure accuracy and appropriateness of prescribed treatments.  Education and skill-building on medication self-management. Clinical staff provide training to promote independence in medication use, including adherence strategies and managing side effects.  Support accessing prescribed medications from local pharmacies or hospitals. Recuperative care staff coordinate with pharmacies to ensure timely delivery and availability of medications.  Behavioral Health Services  Behavioral health screening  Screenings identify behavioral health needs and risk factors, leading to appropriate referrals or brief intervention.  Access to on-site or community behavioral health services for ongoing care. Staff provide brief interventions, or make appropriate referrals for behavioral health.  Brief interventions and referrals for severe or escalating behavioral health needs.  Care Coordination  Care Coordination Plan developed within 72 hours of admission.  Onsite care coordination for aftercare appointments (medical, behavioral health, ancillary services).  Screening and referral to community-based services for SDOH needs.  Linkage to a Primary Care Physician (PCP) if one is not already established.  General Recuperative Care Services  24-hour staffed program with clinical and non-clinical support.  Provision of three meals daily  Secure storage for personal belongings and telecommunication access for medical purposes.  Wellness checks by medical professionals.  Coordination of transportation to medical appointments, housing services, or community resources