Overview

Until recently, "transition planning" has been referred to as "discharge planning." Traditionally, only persons who were leaving an organization were involved in a structured planning process. The switch from "discharge" to "transition" is the result of recognizing that persons leaving one program and entering another are involved in a transition to a different level of care and should be supported by a process that facilitates their ability to maintain and increase their levels of functioning and well-being. The process of transition planning/recovery support services should result in a written plan that is useful to all involved. Everyone should receive a copy of the plan.

Accreditation Requirement(s)

• Procedures are established by the organization for referral, transition to other services, and discharge.
  
• Transition planning begins at the earliest possible point in the planning and service delivery process.
  
• The written transition plan, designed to ensure continuity of service, identifies the gains made in treatment, progress toward recovery, strengths, needs, abilities, and preferences.
  
• The plan is written with input from the client, employees of the program, and family and/or authorized representative, when applicable, as well as from the referral source if appropriate and other community services.
  
• The plan identifies the supports needed for continuing recovery and well-being.
  
• Medications are included in the plan, when applicable.
  
• Referral source information and options available if symptoms recur are also included in the plan.
  
• Anyone who participates in the creation of the plan is given a copy of it, when permitted.
• If other supports are recommended, then a person is identified for follow-up after transition.
  
• If the discharge is unplanned, then personnel are identified who follow up to determine if further services are needed.
  
• If a client is discharged for aggressive or assaultive behavior, follow-up occurs within 72 hours to ensure linkages to other care.

Implementation Tips

Some Implementation Tips provided, in part, by Robert Johnson at: www.accreditationnow.com.

• The old discharge plan model that most behavioral health organizations have utilized has evolved into transitional planning. The discharge plan model typically was a process of paperwork required by organizations operating within a medical model, and served more of a functional purpose for the organization than for the persons served. Typical within this model was a focus on diagnosis and problems, and in most systems, a discharge plan was not required to be completed until after the individual had left the organization.
  
  
• The transitional planning model is an advocacy-based model that includes the full participation of the person served. It is a model that establishes transition planning immediately upon entry to a program. The philosophy is similar to one of Steven Covey's Seven Habits of Successful People: "Begin with the end in mind." In other words, when individuals enter your programs, the end result that the individual seeks should be determined through an assessment and discovery process. This brings self-efficacy into the process by assisting individuals to create the ultimate goal of transition and discharge at the beginning of the process.
  
  
• Educate your providers about the transition planning process, from the assessment to the individual plan to progress reviews, and so on. The issue involved in the person moving to another level of service (program) or leaving a program is that the organization should be fully integrated within all processes of programming.
  
  
• One of the most common deficits organizations have within their systems of clinical care is the lack of transition planning throughout programming. Many organizations indicate that due to the long-term care focus of the more severely disabled behavioral health clients, such as persons in community-based rehabilitation programs, transition planning is not a priority. We believe that it is just as much of a priority for persons with these characteristics as it is for persons not so severely limited. Why? Not recognizing the transition planning process with the more severely disabled only serves to diminish a recovery-based milieu within your clinical system and organization. Transition planning should be fully integrated for all populations served in behavioral health organizations.
  
  
• A transition plan is part of the planning process but is not the process itself. An actual transition plan should be developed with the person served near the time of transition from a program. This plan should be created with input from persons served, and others as appropriate, and a copy of the final plan should be given to anyone who participated in the plan's development upon completion of the plan.
  
  
• A transition plan should be a document in which the individual's strengths, abilities, needs, and preferences are noted. It should describe all the progress and gains that have been made during the program. Consider leaving diagnosis and presenting problems off the transition plan. That information is readily available to providers and referral sources, and only serves to continue to detract from a strengths-based approach if it is the dominant feature on a transitional plan.