Cultural Competence Standards in Managed Mental Health Care

Discharge Planning

Standard
Discharge planning for consumers and families from the four groups 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 a 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 upon goals in the Treatment Plan.

 

Implementation Guidelines

  1. Discharge planning for consumers from the four groups shall involve the consumer, family, or legal guardian who have participated in supporting the consumer's treatment course.
  2. The plan shall include case management and aggressive outreach to assure contact is made with the consumer and family, to minimize "administrative" termination which typically results from culturally inappropriate services.
  3. Discharge planning shall ensure that steps 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 services shall communicate, discuss, and facilitate linkage to the next level of care.
  4. Discharge planning for consumers from the four groups shall acknowledge and recognize the skills needed and the resources available to facilitate a successful recovery program.
  5. Discharge planning for consumers from the four groups shall include the identification of personal, familial, community, and other support systems to help them improve and maintain healthy lifestyles.
  6. Discharge planning for consumers from the four groups shall include an assessment of the biopsychosocial environment to ensure minimum disruption in their quality of life.
  7. Discharge planning shall include identification of a case manager or primary provider to act as the single point of responsibility for coordinating care.
  8. Discharge planning for consumers from the four groups shall include assurances that consumers who fail to return to treatment will receive active follow-up to assure their level of care needs are met.

 

Recommended Performance Indicators

  1. Consumer and family involvement in development of treatment plan.
  2. Documented provision of case management services designed to facilitate linkage to next level of care.
  3. Involvement of consumers and their identified support systems in improving and maintaining the consumer's health.
  4. Documented efforts to contact consumers who fail to return for treatment.

 

Recommended Outcomes

  1. Consumer and family satisfaction with discharge plans.
    Benchmark: 90% satisfaction via an independent evaluator.
  2. Consumer involvement with discharge plan.
    Benchmark: 100% documented involvement.
  3. Consumer remains connected to health care system in accordance with treatment plan.
    Benchmark: 100% documented involvement.
  4. No more than 10% of consumers from the four groups in the plan who receive restrictive level of care services experience recidivism.
    Benchmark: No more than 10% documented recidivism.