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

2. 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.

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

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

5. 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

6. 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

7. 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

8. 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

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

10. 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

11. 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)

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

13. 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

14. 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

15. 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

16. 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.

17. 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