Standard and Guidelines for Discharge Planning

Standard

Discharge planning for consumers and families of African descent must include involvement of the consumer and family in the development and implementation of the plan and evaluation of outcomes. Discharge planning must be done within a culturally competent framework and in a communication style congruent with the consumer’s values. The plan must allow for transfer to less restrictive levels of care in addition to termination of treatment based on accomplishment of mutually agreed terms of the treatment contract. The plan must include case management and aggressive outreach to assure contact is made with the consumer and family to avoid the tradition of "administrative" termination which may be the result of culturally inappropriate services.

Implementation Guidelines

1. Discharge planning for consumers of African descent must involve the consumer, family, or legal guardian to the extent that the consumer wants family involvement. Decisions made by the consumer regarding family involvement must be documented in the medical record.
   
   

2. Discharge planning must identify goals at the initial point of assessment.
   
   

3. Discharge planning must include documentation that steps were taken to address linkages to the next level of care, and that a reasonable effort to define the next steps in treatment was made. The provider of case management must communicate, discuss, and facilitate the linkage to the next level of care.
   
   

4. Discharge planning for consumers of African descent must include the acknowledgment and recognition of skills needed and available resources to facilitate a successful recovery program.
   
   

5. Discharge planning for consumers of African descent must include the identification of personal, familial, community, and other support systems’ strengths to help them improve and maintain healthy lifestyles.
   
   

6. Discharge planning for consumers of African descent must include an assessment of the biopsychosocial environment to ensure minimum disruption in the quality of the consumer’s life.
   
   

7. Discharge planning must include identification of a primary provider to act as the single point of responsibility for coordinating care.
   
   

8. Discharge planning for consumers of African descent must include assurances that consumers who fail to return to treatment will receive three (3) active follow-up contacts, and these contacts are to be documented in the medical record.
   

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