Behavioral Health Standard 2.D – Transition/Discharge


The program implements written procedures for:

  1. Referrals
  2. Transfer to another level of care, when applicable
  3. Transfer to other services
  4. Inactive status, if appropriate
  5. Discharge
  6. Follow-up
  7. Identifying:
    1. When transition planning will occur
    2. Where the following are documented:
      1. Transitional planning
      2. Discharge summary
  • ???


Transition planning is initiated with the person served as soon as clinically appropriate in the person-centered planning and service delivery process.

  • ???


The written transition plan:

  1. Is prepared or updated to ensure a seamless transition when a person served:
    1. Is transferred to another level of care or an aftercare program
    2. Prepares for a planned discharged
  2. Identifies the person’s current:
    1. Progress in his or her own recovery or move toward well-being
    2. Gains achieved during program participation
  3. Identifies the person’s need for support systems or other types of services that will assist in continuing his or her recovery, well-being, or community integration
  4. Includes information on the continuity of the person’s medication(s), when applicable
  5. Includes referral information, such as contact name, telephone number, locations, hours, and days of services, when applicable
  6. Includes communication of information on options and resources available if symptoms recur or additional services are needed, when applicable
  7. Includes:
    1. Strengths
    2. Needs
    3. Abilities
    4. Preferences
  • ???


The written transition plan is:

  1. Developed with the input and participation of:
    1. The person served
    2. The family/legal guardian, when applicable and permitted
    3. A legally authorized representative, when appropriate
    4. Team members
    5. The referral source, when appropriate and permitted
    6. Other community services, when appropriate and permitted
  2. Given to individuals who participate in the development of the transition plan, when permitted
  • ???


The program implements procedures for referrals and transfers to ensure that the process is effectively completed.

  • ???


For all persons leaving services, a written discharge summary is prepared to ensure that the person served has documented treatment episodes and results of treatment. The discharge summary:

  1. Includes the date of admission
  2. Describes the services provided
  3. Identifies the presenting condition
  4. Described the extent to which established goals and objectives were achieved
  5. Describes the reasons for discharge
  6. Identifies the status of the person served at last contact
  7. Lists recommendations for services or supports
  8. Includes the date of discharge from the program
  9. Includes information on medication(s) prescribed or administered, when applicable
  • ???


When an unplanned discharge occurs, follow-up is conducted as soon as possible to:

  1. Provide necessary notifications
  2. Clarify the reasons for the unplanned discharge
  3. Determine with the person served whether further services are needed
  4. Offer or refer to needed services
  • ???


When a person is transferred or discharged, the program identifies:

  1. A process to ensure coordination
  2. The person responsible for coordinating the transfer or discharge
  • ???