GAPP Knowledge Center
Transitioning from the hospital to home care under GAPP
For many medically complex children, GAPP begins with a hospital-to-home transition — often following an extended NICU, PICU, or inpatient stay. Core Health Group Corp. specializes in these transitions, coordinating with hospital teams to ensure the child arrives home safely with the nursing coverage they need.
Why Hospital-to-Home Transitions Are Complex
Transitioning a medically complex child home from the hospital requires coordination across multiple systems:
Clinical
The child's physician team must document medical necessity and authorize a plan of care.
Insurance / Medicaid
GAPP prior authorization must be in place before discharge (or an emergency authorization obtained).
Equipment
Durable medical equipment (DME) — ventilators, feeding pumps, suction machines — must be delivered and set up at home.
Staffing
Nursing staff must be assigned, oriented to the child's specific equipment and protocols, and scheduled.
Family
Parents and caregivers must be trained and prepared before the child arrives home.
Home environment
The home must be assessed for safety and clinical suitability.
Core Health Group Corp.'s Transition Process
Our step-by-step process ensures nothing falls through the cracks between the hospital and home:
Early Contact
Ideally, families contact us 2–4 weeks before anticipated discharge. Early engagement allows us to begin the authorization process before the child is ready to leave the hospital, preventing delays at discharge.
Intake and Assessment
Our clinical intake team reviews the child's medical record, current diagnosis, and anticipated care needs. We assess staffing requirements and equipment needs.
Authorization Submission
We coordinate with the hospital's discharge planning team and the attending physician to assemble and submit the GAPP prior authorization packet to Alliant Health Solutions.
Home Assessment
A clinical coordinator visits the home to assess the physical environment, identify any safety modifications needed, and confirm DME placement.
Staff Assignment and Orientation
We assign and orient nursing staff to the child's specific protocols, equipment, and emergency procedures before the discharge date.
Discharge Day
Core Health Group Corp. nursing staff are present at or arrive shortly after the child comes home. We ensure a seamless handoff from the hospital team.
Ongoing Coordination
We maintain communication with the physician team and adjust the care plan as the child's needs evolve at home.
What Families Should Do
Steps families can take to prepare for a successful hospital-to-home transition:
- Contact Core Health Group Corp. as early as possible — ideally as soon as discharge planning begins
- Ask the hospital discharge planner to include Core Health Group Corp. in discharge planning meetings
- Ensure your child is enrolled in Georgia Medicaid (or begin the Katie Beckett / TEFRA enrollment process if not)
- Identify which family members will be trained as primary caregivers
- Prepare your home: review space for equipment, ensure working electrical outlets, contact your utility company about medical equipment priority status
- If your child will have a ventilator or other life-sustaining equipment, register with your utility company as a medical priority customer
Frequently Asked Questions
What if my child's discharge is sudden and we haven't arranged GAPP yet?
Contact us immediately. Core Health Group Corp. can initiate an emergency authorization process and work with the hospital team to coordinate as rapidly as possible. We have experience with time-sensitive discharges.
Can nursing care start the same day as discharge?
Our goal is always to have nursing coverage in place on day one. When transitions are planned in advance, we can usually achieve this. For emergency discharges, we work as quickly as possible to staff the case.
What happens if GAPP authorization isn't approved before discharge?
We work with the hospital team to either delay discharge until authorization is in place or obtain an emergency bridge authorization. We rarely allow a child to go home without coverage confirmed.
Who coordinates the DME delivery?
DME is typically coordinated by the hospital discharge planner or the child's Medicaid case manager. Core Health Group Corp. can assist by confirming equipment requirements and communicating with the DME provider.
Is there a cost for the hospital-to-home coordination services?
No. Transition coordination is part of our service to families. GAPP covers the approved in-home services; there is no separate charge for the transition planning work Core Health Group Corp. provides.
Free Eligibility Screening
Planning a discharge? Contact us early.
The sooner Core Health Group Corp. is involved, the smoother the transition. Reach out now to start the authorization process and ensure nursing coverage is in place before your child comes home.