CONTINUUM OF CARE & DISCHARGE PLANNING
CONTINUUM OF CARE
This section/training module is designed to give you a knowledge base about the goals and
objectives for Residential Services, Delaware House, Catholic Charities. Further
information regarding these levels of service can be found in the Delaware House Policies
& Procedures Manual.
Level A+ Intensive Residential Programs
This is a permanent residential placement option for seriously mentally ill adults who are
“typically hard to place”, have been in a State Hospital for a minimum of 6 consecutive
months, and who have a history of previous unsuccessful community placements. The
central focus of this setting is to provide a healthy, safe and supportive living environment
with the aim to reduce over-stimulation, stressful relationships, and anxiety producing life
events through simple, clear, concise communication and expectations.
Level A Long Term Supervised Residency
This residence is designed to provide supervised supportive housing for consumers who
have experienced severe and prolonged mental illness, which has seriously affected their
level of functioning in daily living. It is common that these consumers have also
experienced serious substance abuse problems, which without supervision and assistance,
will resurface. There is no imposed length of stay in this level of Residency, thereby
allowing consumers with very serious problems to be able to continue receiving this level
of care for an indefinite period of time. This residence is generally not staffed during
daytime hours because the residents attend Partial Care Programs, however there is built-in
flexibility to provide this coverage when needed.
Level A Transitional Residency
This residential option is comprised of short-term community living situations for
consumers being discharged from psychiatric hospitals with the average length of stay
being from 3 to 6 months. This is a starting point at which assessment of living skills,
psychiatric stability, medication/treatment compliance and independence in daily routines
is performed to facilitate decision making as to what type of long-term living situation
would best meet an individual’s needs. These group homes are supervised from 3 PM to 8
AM, Mon- Fri, and 24 hours per day on weekends. They also serve as “crisis respite”
options for consumers in less supervised settings who are experiencing temporary
difficulties. A significant percentage of the residents have histories of substance abuse,
therefore emphasis is put on teaching how to become sober and to begin establishing
community supports to maintain sobriety. Transitional housing includes less supervised
living situations to which consumers from the group homes move.
Supportive Housing
An option for consumers who are ready to leave Agency owned or leased housing and
establish their own living situations while continuing to receive mental health support
services.
Home Care
Delaware House trains and contracts with community residents to provide services to
consumers. The consumers live with the “Provider” and their family. This is particularly
effective for consumers who require a long-term “permanent” living situation that is very
supportive and does not require them to live with other mentally ill consumers.
Common elements that are important in every level of the Residential Continuum:

Promoting a structured and predictable environment

Realistic performance requirements.

Adult to Adult vs. Parent to Child interactions and communication patterns
between the staff members and consumers.

Non-judgmental regard and respect for the consumer.

A coaching model and approach vs. an authoritarian approach taken by
staff.

Staff awareness and knowledge of the stigma surrounding mental illness.
It is every consumer’s right to live in the least restrictive setting that adequately provides
for his or her need of support. It is important that the Recovery Plan of every consumer
address the discharge of that consumer from one level of the Delaware House continuum to
another or to a situation outside of the continuum.
DISCHARGE PLANNING PROCEDURES
The circumstances surrounding the discharge process can either be initiated by the
consumer or by the program. In either case, there are several important factors to consider
relative to the after-care and follow-up planning that is integral in ensuring the well being
and safety of the consumer and whether or not their re-entry back into the community will
be successful.
Procedure for Discharge from Residential Services Initiated by Consumer

The consumer and his or her Residential Specialist shall fully discuss the discharge.
The Specialist, in teaming with the consumer, will make every effort to ensure the
plan is viable and in the best interest of the consumer.

If, despite treatment team recommendations, the consumer insists on leaving
Residential Services, the Specialist shall do the following:
a. If Catholic Charities is Representative Payee for benefits, inform the
consumer we are obligated to continue overseeing these funds until
another Representative Payee is arranged for with Social Security.
b. Try to negotiate a commitment from the consumer to follow through with
treatment to some degree even though she/he is leaving Residential
Services and assist the consumer in making appropriate arrangements.
c. Depending on the specific circumstances, the Specialist will discuss with
the Residential Services Director in holding the bed open for a period not
to exceed two weeks. The decision to do this or not is dependent upon the
agreed likelihood that the consumer’s plan is not realistic and we hope to
be able to convince them to return.
Procedure for Discharge from Residential Services Initiated by the Program
The decision to discharge a consumer from Residential Services must be discussed
and agreed upon by the Residential Specialist and a Residential Director.
This decision is based on the following factors:

The consumer is refusing to follow treatment recommendations and as a
result is engaging in behavior that is detrimental to him/herself and/or
others in the residence.

Repeated efforts to intervene in this behavior and to explain the
consequences to the consumer by the Residential Specialist and Residential
Staff have been unsuccessful in impacting on the situation. These efforts
must be clearly documented.

If the consumer expresses strong disagreement with the decision, the
Specialist will explain the “Client Compliant/Agency Ombuds Procedure”.

The Residential Specialist will make a reasonable effort to assist the
consumer in finding alternative housing and encourage the consumer to
continue with some mental health services. These efforts must be clearly
documented.
If after the above has been done and the consumer wants to appeal his/her discharge, the
Residential Specialist will explain the following steps:
1. The decision to discharge and all intervention attempts will be
documented and submitted to the Catholic Charities Burlington County
Division Director for review.
2. If the Division Director upholds the decision and the consumer still
disagrees, a meeting will be scheduled for administrative review with
the Division of Mental Health Services Program Analyst.
3. The decision to discharge will either be upheld or other solutions
negotiated with the consumer and Agency

If a consumer leaves Residential Services, the space will be kept open for
thirty days or until we are sure the consumer will not be returning.

If a consumer leaves Residential Services, we will store their belongings for
a minimum of two weeks and a maximum of ninety days

Residential Services will not discharge a consumer as retaliation for trying
to state or obtain his/her rights.