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;
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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
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