NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS
POLICY TITLE: Transition and Discharge Plan for Continuing Care
PAGE: 1 of 4
MANUAL: Clinical
SECTION: Service Monitoring & Eval.
ORIGINAL EFFECTIVE DATE: 4/1/03
BOARD APPROVAL DATE: 9/26/13
REVIEWED/REVISED ON DATE: 11/12/15
CURRENT EFFECTIVE DATE: 12/1/15
REVISIONS TO POLICY STATEMENT:
YES
NO OTHER REVISIONS:
YES
NO
APPLIES TO:
All services offered by Northpointe
POLICY:
It is the policy of Northpointe Behavioral Healthcare Systems that Transition Planning will be addressed continually to
encourage movement to lesser restrictive services. Transition planning is initiated at the earliest possible point in the
assessment/person centered planning process, and is based on the needs of the person served. Transition is addressed at
least annually in the IPOS. Adequate planning for the discharge of individuals screened and approved for inpatient
psychiatric hospitalization will ensure a safe transition to home/community.
PURPOSE:
To provide guidelines to assist staff in transitioning individuals. Transition Planning begins at intake. The transition may
include discharge planning, or transfer to a different level of service or provider.
A transfer or discharge is documented when:
(1) An individual is changing providers whether by choice or by the fact that a worker is leaving Northpointe
employment;
(2) An individual is transferring to a different level of care,
(3) An individual is leaving a Northpointe program;
(4) An individual is discharged from a psychiatric unit.
PROCEDURES:
TRANSFER OF SERVICE RECIPIENT: Requests for a new provider to be made in writing go to the site
director who will discuss with the treatment team. If it is a request for a new prescriber, their clinical supervisor
will be involved.
A.
If an individual requests to transition a provider or stay with a provider when geographic location would
normally facilitate a transfer, a clinical supervisor not directly involved in the individual’s care (i.e.
providing direct services )in conjunction with the treatment team, approves or disapproves the transfer, based
on clinical judgment using service guidelines. This will be documented in treatment team meeting minutes
and discussed with the clinical supervisor and receiving provider if the receiving provider is not available at
the time of the team meeting.
B.
After the transfer has been approved by the supervisor/treatment team, it is routed to the receiving provider.
If a transfer cannot occur due to a capacity issue, it will be noted in treatment team meeting minutes and
monitored as clinically appropriate. If the treatment team/supervisor that approved the transfer is from a
different county than the county the service recipient will receive services ongoing, the supervisor/treatment
team in the county where the services will be ongoing will re-evaluate as needed on an ongoing basis if the
transfer appears to continue to be clinically appropriate as described above. If the individual receiving
services has a need for specialized care not available by a provider within the county they live, a provider
from another county may provide those services otherwise services will be provided in the county in which
the individual resides.
C.
The current provider is responsible for all aspects of care with an individual until the new provider has been
assigned.
D.
The current primary case-holder must:
(1)
Complete an updated BPS assessment to validate any changes in the Level of Care, making sure
the individual’s record is complete and accurate,
NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS
POLICY TITLE: Transition and Discharge Plan for Continuing Care
PAGE: 2 of 4
MANUAL: Clinical
SECTION: Service Monitoring & Eval.
ORIGINAL EFFECTIVE DATE: 4/1/03
BOARD APPROVAL DATE: 9/26/13
REVIEWED/REVISED ON DATE: 11/12/15
CURRENT EFFECTIVE DATE: 12/1/15
(2)
Complete an IPOS amendment to revise goals and objectives and to authorize services as
clinically appropriate.
(3)
Early Terminate current authorizations when applicable,
(4)
Update the Staff Assignments in the Admissions and Assignments tab in ELMER to indicate
who the case is being transferred to, the date on which this is to occur, and the expiration date of
all current provider(s) assignment(s). There should be a continuity flow showing all assignments
without gaps in service time.
(5)
Action notices are given/mailed to the individual when there are any reductions, terminations or
denials of services.
E.
If an individual is being transferred to a specialized Residential facility, the Placement Review Committee
will meet prior to residential placements or transitions. Persons served have the options to move to
community integrated settings, as appropriate; court orders and the need to extend them will be discussed as
clinically indicated. IPOS Amendment may need to be completed to authorize Personal Care and Community
Living Supports on the day of admission to the residential facility.
DISCHARGING INDIVIDUALS FROM NORTHPOINTE SERVICES:
A.
A discharge is completed when an individual has met their goals as directed in their IPOS and is being
discharged from Northpointe services as agreed upon by the individual, their care manager and any other
professionals involved in the individual’s treatment.
B.
An unplanned discharge may occur due to lack of follow through from the individual, i.e. cancelling or no
showing their appointments, and the care manager does not feel the individual will return for services.
Before these unplanned discharges occur; the provider must make outreach attempts with the individual and
document these efforts in Progress notes before a clinical decision is made to close the case. Clinician will
staff the closure with the treatment team prior to an unplanned discharge.
C.
All individuals receiving prescribed medications from a Northpointe practitioner must be referred to a
private practitioner prior to the discharge.
D.
A discharge summary will be completed in its entirety for all discharged individuals.
E.
Discharge summary will be signed by clinician, routed to and signed by their supervisor and practitioner as
applicable.
F.
All service providers must be informed of the closure (i.e. Trico, Goodwill, OT, and PT).
G.
All authorizations must be early terminated.
H.
All Releases of Information must be terminated/expired.
I.
Action Notice must be given/sent to individual notifying them of the case closure. Case is closed 14 days
after the Notice being given/sent.
DISCHARGING OPEN INDIVIDUALS FROM A PSYCH UNIT
A.
The Northpointe Emergency Services Specialist and the Primary care manager must be actively involved in
discharge planning activities.
B.
Discharge Planning activities are to be documented in ELMER at time of activity and no later than the next
business day.
NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS
POLICY TITLE: Transition and Discharge Plan for Continuing Care
PAGE: 3 of 4
MANUAL: Clinical
SECTION: Service Monitoring & Eval.
ORIGINAL EFFECTIVE DATE: 4/1/03
BOARD APPROVAL DATE: 9/26/13
REVIEWED/REVISED ON DATE: 11/12/15
CURRENT EFFECTIVE DATE: 12/1/15
C.
A follow-up appointment with the primary care manager must be provided as soon as possible and no longer
than 7 days of hospital discharge. If Primary care manager is not available in the next 7 days, the individual
shall be scheduled to see the Worker of the Day within 7 days of discharge.
D.
Follow-up appointment with the psychiatric prescriber must be provided prior to discharge medications
running out.
E.
Northpointe Hospital Discharge Peer Supports Specialist (PSS) and Emergency Services staff will be
notified of discharge and after care appointments/plans.
F.
A minimum of 3 Outreach phone call attempts and/or a letter sent to assess how the person is doing and to
remind, clarify, assist with aftercare appointments will be completed by the Peer Support Specialist.
G.
The Back up Supervisor (BUS) should be consulted with prior to readmission within the 30 days period.
DISCHARGING INDIVIDUALS WHO ARE NOT OPEN AT ADMISSION BUT FOLLOW UP WITH
NORTHPOINTE ON DISCHARGE FROM A PSYCH UNIT
A.
The Northpointe Emergency Services Specialist must be actively involved in discharge planning activities.
B.
Discharge Planning activities are to be documented in ELMER at time of activity and no later than the next
business day.
C.
A face to face appointment must be provided within 7 days of hospital discharge for individuals approved
by NorthCare Access Screener for Northpointe services. This appointment will preferably be the intake
assessment but if intake appointment not available then the individual must be seen by Worker of the Day or
other clinical staff. An intake appointment should also be scheduled.
D.
Follow-up appointment with a psychiatric prescriber must be provided prior to discharge medications
running out, if the person chooses or is court ordered to come to Northpointe for this service on discharge.
E.
Northpointe Hospital Discharge Peer Supports Specialist (PSS) and Emergency Services staff will be
notified of discharge and after care appointments/plans.
F.
A minimum of 3 Outreach phone call attempts and/or a letter sent to assess how the person is doing and to
remind, clarify, assist with aftercare appointments will be completed by the Peer Support Specialist.
G.
The Back up Supervisor (BUS) should be consulted with prior to readmission within the 30 days period.
DISCHARGING INDIVIDUALS FROM A PSYCH UNIT WHO DO NOT FOLLOW-UP WITH
NORTHPOINTE
A.
The Northpointe Emergency Services Specialist must be actively involved in discharge planning activities.
B.
Discharge Planning activities are to be documented in ELMER at time of activity and no later than the next
business day.
C.
Follow-up appointments with alternative providers must be documented, if there is a Release of Information
to Northpointe, or if Northpointe is the payee, for people who are not approved for or not requesting
Northpointe services.
D.
If an individual refuses a follow-up appointment with an alternative provider, this must also be documented.
E.
Northpointe Hospital Discharge Peer Supports Specialist (PSS) and Emergency Services staff will be
notified of discharge and after care appointments/plans.
NORTHPOINTE BEHAVIORAL HEALTHCARE SYSTEMS
POLICY TITLE: Transition and Discharge Plan for Continuing Care
MANUAL: Clinical
ORIGINAL EFFECTIVE DATE: 4/1/03
REVIEWED/REVISED ON DATE: 11/12/15
PAGE: 4 of 4
SECTION: Service Monitoring & Eval.
BOARD APPROVAL DATE: 9/26/13
CURRENT EFFECTIVE DATE: 12/1/15
F.
A minimum of 3 Outreach phone call attempts and/or a letter sent to assess how the person is doing and to
remind, clarify, assist with aftercare appointments will be completed by the Peer Support Specialist.
G.
The Back up Supervisor (BUS) should be consulted with prior to readmission within the 30 days period.