CENTRAL OHIO MENTAL HEALTH CENTER Subject: Transition and Discharge Summary Section: 04.14.01.00 Effective Date: 10/28/2010 Approved by: ______________________________ Gary Bell, Board President PURPOSE: To provide a methodology for transitioning services between programs and ultimately terminating services with a client in compliance with the Ohio Administrative Code established by the Ohio Department of Mental Health and other regulatory bodies. POLICY: Central Ohio Mental Health Center shall complete a transition or discharge summary of the services provided to a client when the client is being transitioned from behavioral health treatment services, has completed treatment, or is unexpectedly terminated from behavioral health treatment services. When the client has unexpectedly terminated services, the Center shall document in the client’s integrated client record (ICR) attempts by the Primary Provider or other clinical staff attempts to contact the client and/or parent/legal guardian prior to completing a discharge summary. I. When clinically indicated, transition or discharge planning shall be initiated at the earliest possible point in the individual planning and service delivery process. II. The transition or discharge summary shall include, but not be limited to, the following information: A. Date of admission of the client; B. Date of the last service provided to the client; C. Initial presenting problem or conditions; D. Reason for transfer or discharge; E. Services provided during treatment; F. Identifies the client’s current progress in recovery or movement toward well being, gains achieved during program participation, strengths, needs, abilities, and preferences; G. Identifies the person’s need for support systems or other types of services that will assist in continuing his/her recovery or well being; H. Recommendations made to the client, as appropriate to the individualized service plan (ISP), including referrals made to other community resources; I. Provides referral source information such as contract name, telephone number, location, hours, and days of service; J. Medications prescribed by the agency upon the client’s termination from service; K. Communicates information on options available if symptoms recur or additional services are needed; 2/12/2016 Page 1 of 2 106727600 L. M. Upon involuntary termination from service, documentation that the client was informed of his/her right to file an appeal; and Dated signature and credentials of the staff member completing the summary and Clinical Supervisor, when applicable. III. The transition plan will utilize input from and include participation of the client, the family when appropriate and permitted, a legally authorized representative when appropriate, clinical staff, the referral source, when appropriate and permitted, and other community service providers when appropriate and permitted. IV. A copy of the transition or discharge plan will be provided to the client and all transition planning participants when beneficial to and permitted by the client and when it will assist the referral source or receiving program with providing continuity of service delivery. A copy of the transition or discharge plan may be sent or mailed to the client at the location of their choice if the client is not available. Distribution of transition or discharge planning shall be documented in the client’s IRC. V. Where needs for additional services of supports are indicated in the transition plan, the Primary Provider in the accepting program will be responsible for follow-up after transition and will be responsible to: A. Maintain the continuity and coordination of needed services B. Determine, with the client, whether further services are needed; C. Offer or refer client to needed services when possible VI. When unplanned transition or discharge occurs, the Primary Provider, will be responsible for follow-up to determine, with the client, whether further services are needed and to offer or refer the client to needed services when possible. VII. Persons discharged from a program due to assaultive or aggressive behaviors will be referred and linked with appropriate behavioral healthcare services within three (3) calendar days of discharge. VIII. The transition or discharge summary shall be completed and signed by the client’s Primary Provider and Clinical Supervisor, when appropriate within 30 days of the client’s last service in a program, last appointment, or the last attempt of the Provider to contact the client when the client has not returned for services or unexpectedly terminated services. The only exception to the 90-day rule will be those clients who are seen by the center psychiatrist only and the rule for these clients shall be closure within 180 days. The transition or discharge summary will be filed in the Individual Client Record (ICR) according to the Center’s Integrated Client Record Management System procedure (05.05.02.01). Revision: 07/28/2005 Approved: 01/01/1993 2/12/2016 Page 2 of 2 106727600