Ohio Admin. Code 5122-41-05 - Care coordination, transition planning, and continuity of care
(A)
The PRTF coordinates care with other providers during
treatment, as part of transition planning and after treatment.
(B)
The PRTF
recognizes that transition to the community is challenging for the youth and
family or caregiver and assures that services and supports are in place to
support the youth's successful return to the community.
(C)
Individualized
transition planning begins within twenty-four hours of admission with a strong
focus on family and caregiver education and engagement in the care of youth,
and coordination with partnering entities.
(D)
The PRTF partners
with OhioRISE care coordination to develop discharge plan back into the
community that includes consistent collaboration during the youth's PRTF
stay.
(E)
The PRTF partners with the youth and family to engage
and utilize natural community supports as part of transition
planning.
(F)
The PRTF coordinates with community providers or
partners prior to the transition to ensure services are not
interrupted.
(G)
PRTFs serving youth with co-occurring behavioral health
and intellectual or developmental disabilities will coordinate with the
department of developmental disabilities assigned regional
coach.
(H)
The PRTF will make training available to family and
community partners, as needed to serve the needs of the youth.
(I)
The PRTF is
available to community partners, as well as the youth and family or caregiver
at least six months post discharge when the youth is transitioned to a
community setting, including at least monthly contact with the youth and family
or caregiver unless the youth and family or caregiver decline this contact when
the PRTF discusses it and offers it as part of discharge
planning.
(J)
The PRTF provides written documentation to all
participants of the transition plan at least forty-eight hours prior to the
youth leaving the PRTF with information on how to access additional supports
from the PRTF and community providers including contact information and steps
necessary to access each provider.
Notes
Promulgated Under: 119.03
Statutory Authority: 5119.141
Rule Amplifies: 5119.141, 5119.34
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