Cultural Competence Standards in Managed Care Mental Health Services for Asian and Pacific Islander Americans

Discharge Planning

 

Standard

Discharge planning for APIA consumers and families shall include involvement of the consumer and family in the development and implementation of the plan and evaluation of outcomes. Discharge planning shall be done within an APIA culturally competent framework and in a communication style congruent with the consumer’s values. The plan shall 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 shall include case management and aggressive outreach with the APIA consumer and family, to minimize "administrative" termination which is typically the result of culturally inappropriate services.

 

Implementation Guidelines

  1. Discharge planning for APIA consumers shall involve the consumer, family, or legal guardian to the extent that the consumer wants family involvement. Decisions made by the consumer regarding family involvement shall be documented in the medical record.
  2. Discharge planning for the APIA consumer shall identify goals at the initial point of assessment.
  3. Discharge planning for APIA consumers shall include documentation of steps that were taken to address linkages to the next level of care. Documentation shall also demonstrate that a reasonable effort to define the next steps in treatment was made. The provider of case management shall communicate, discuss, and facilitate the linkage to the next level of care.
  4. Discharge planning for APIA consumers shall include the acknowledgment and recognition of skills needed and available resources to facilitate a successful recovery program.
  5. Discharge planning for APIA consumers shall include the identification of personal, familial, community, and other support systems’ strengths to help them improve and maintain healthy lifestyles.
  6. Discharge planning for APIA consumers shall include an assessment of the biopsychosocial environment to ensure minimum disruption in the quality of the consumer’s life.
  7. Discharge planning for the APIA consumer shall include identification of a primary provider to act as the single point of responsibility for coordinating care.
  8. Discharge planning for APIA consumers shall include assurances that consumers who fail to return to treatment shall receive three (3) active follow-up contacts. These contacts shall be documented in the medical record.

 

Recommended Performance Indicators

  1. Discharge planning shall include APIA consumer and family participation.
  2. Linkages to next level of care, including natural support systems, shall be established and coordinated.
  3. Functional and environmental assessments shall inform discharge planning.
  4. Providers shall attempt at least three (30 follow-up contacts before instituting discharge planning.

 

Recommended Outcomes

  1. APIA consumer satisfaction with linkages to care.
    Benchmark: 90% consumer satisfaction.
  2. Documentation of functional and environmental assessments.
    Benchmark: 100% documentation.
  3. Documentation of follow-up contacts.
    Benchmark: 100% documentation.