Beaver County Single Point of Accountability Transition of Care / Transition Planning Protocol

Mission/Definition of SPA Provide linkage, continuity, accountability, and communication across the full spectrum of consumer services.  In Beaver County System of Care, SPAs are The Safety net The Go-to individual for the system: assessing, planning, coordinating, and advocating to break down system barriers. Planning is consumer driven and involves family and significant others, and collaboration/integration among all systems involved in the person's life.

Transition Planning Transition Planning is an essential component of Single Point of Accountability.

The Goal of Transition Planning Assure seamless transition for consumers from one level of care to another.

The 3 C’s of Transition Planning Continuity, Coordination, and Communication Objective is to provide CONTINUITY of care The referring agency takes the lead in COORDINATING the transition It is important to COMMUNICATE the plans within the agency and across the continuum of care for the whole person

Types of Transitions of Care From/To same level of care Example: BCM to BCM From higher level of care to a lower level of care Example: ACT to BCM; BCM to Admin From a lower level of care to a higher level of care Example: Admin to BCM; BCM to F/ACT

Billing During Transitions of Care Transitions from BCM to BCM Both agencies can bill VBH for 1 transition meeting Agencies should contact BCBH if additional transition meetings are required Transitions involving F/ACT F/ACT Eligibility Requirements on slides 15 and 16 Both agencies can bill VBH

The Transition Planning Process Develop a Transition Plan Conduct a Face-to-Face meeting with the consumer and transitioning SPAs Update the service plan and other supporting documentation Conduct a transitional treatment team meeting (if needed) Update eSP

1. Develop a Transition Plan A Transition Plan is vital to assure continuity of care and successful/seamless transition.

The Transition Plan Referring agency is responsible for developing the Transition Plan Plan should include the following: Consumer demographic information Referring agency, level of care, and case manager Receiving agency and level of care Clear indication of who is responsible for communicating and coordinating transition Length of the transition period, including an end date. Summary of Plans, Goals, Services, and Resources Intake / Discharge information, especially to/from higher levels of care (see F/ACT Transition Plan slide) Involvement of other systems (CYS, Justice, etc.) Medical conditions An updated Crisis Prevention Plan from eSP

2. Conduct a Face to Face meeting with the consumer and transitioning SPAs Allow for overlap Meet face-to-face with the consumer and the two levels of care (providers) This should be individualized and is driven by clinical need More than one face-to-face meeting may be required in order to ensure the consumer is comfortable with the new team (esp. when transitioning from F/ACT to lower levels of care)

3. Update the service plan and other supporting documentation The transition must be noted in the Service Plan and supporting documentation.

4. Conduct a Transitional Treatment Team meeting If needed, the two levels of care have the option of having a Transitional Treatment Team meeting, including: The consumer Other involved agencies (CYS, Justice, etc.) Physical Health Peers Significant others Family members Other natural supports

5. Update eSP Search for and select the person on the “Consumer Maintenance” screen. If needed, remove check mark from the “Associated Provider View Access” checkbox – click Change Select “Service Plan / eSP Domains Screen” (on bottom of screen) Select the “SPA” domain End date the active SPA record – click Change Notify new SPA that the old record has been closed and that they should contact BCBH to assign the consumer to the new SPA’s agency New SPA should contact BCBH to have consumer assigned to their agency Once BCBH has linked the new agency, go to the “SPA” domain and add a start date for the new SPA in the SPA domain

Eligibility Requirements for F/ACT Must Complete the NHS REFERRAL FORM FOR F/ACT 18 years of age or older, AND has been diagnosed with a serious and persistent mental illness DIAGNOSIS: Primary diagnosis of Schizophrenia or other Psychotic Disorders AND FUNCTIONING LEVEL: GAF ratings of 40 or below, OR, GAF Rating of 60 or below if the individual is 35 years of age or younger and has a documented history of violent or aggressive behavior

Eligibility Requirements for F/ACT: Cont. INDICATORS OF CONTINUOUS HIGH SERVICE NEEDS: Three (3) or more psychiatric and/or substance abuse hospitalizations; OR, one (1) psychiatric hospitalization over thirty (30) days in the past twelve (12) months; OR For a forensic team, one (1) psychiatric hospitalization, or, documented evidence by a psychiatrist that behavioral health services were provided in the last 12 months, AND one (1) incarceration of more than six (6) months, or three (3) jail detentions in a twelve (12) month period.; AND Inability to participate or remain engaged or respond to traditional community based services. (Documented evidence exists demonstrating efforts to engage the individual by a treatment or case management provider for forty-five (45) days and supporting documentation that without behavioral health treatment and support, the individual's well being and stability will be jeopardized) AND At least two (2) of the following criteria: Co-occurring mental illness and substance use disorders with more than six months duration at the time of contact. Intractable, persistent or very recurrent severe major symptoms (ex., affective, psychotic, or suicidal with inability to ignore; or, life threatening physical harm to self or others with or without follow through; or, impulsive acting out, physical assault or uncontrolled anger that resulted in physical harm or real potential harm to others (ex., assault, rape, arson); Lack of support system; limited to no support from family, other professionals, friends, and social programs; History of inadequate follow-through with elements of a treatment/service plan that resulted in psychiatric or medical instability (lack of follow through taking medication, following a crisis plan, attending to health needs, or maintain housing); Literally homeless, imminent risk of being homeless, or residing in unsafe housing; or, residing in an inpatient or supervised community residence, but clinically assessed to be able to live in a more independent living situation if intensive services are provided, or requiring a residential or institutional placement if more intensive services are not provided.

THANK YOU You have completed the Transition of Care / Transition Planning Protocol. Please take the test! You will get a certificate once you have completed all the competencies and passed with 90% or better. The certificate will generate on its own. Print it. Give it to your supervisor