309-018-0155 Transfer and Continuity of Care (1) Providers shall maintain direct affiliation with or close coordination for referral to other levels of care and other types of services and supports to coordinate biomedical, psychological, pharmacotherapy, laboratory, community engagement, educational, vocational and other such services and supports that are not offered by the provider. (2) Prior to transfer, providers shall: (a) When applicable, coordinate and provide appropriate referrals for medical care and medication management. The transferring provider shall assist the individual to identify the medical provider who provides continuing care and to arrange an initial appointment with that provider; (b) Document a transfer summary of treatment services; and (c) Report all instances of transfers on the mandated state data system. (3) A transfer summary of treatment services shall include: (a) The date of transfer; (b) The reason for the transfer; (c) When transfer is to another provider, identify the provider where services are to be transferred, including contact information and date of admission or description of steps for the individual to access services; (d) For substance use disorder treatment services, a summary of the current ASAM data for all dimensions, risk assessment, the ASAM assessed Level of Care established for the purposes of transfer of services, and any other recommendation(s) for the next assessed ASAM Level of Care, including other community services; and (e) A summary statement describing the effectiveness of services to assist the individual and, when applicable, their family in achieving the objectives contained in the service plan . (4) A transfer summary of support services shall be made available in writing to the individual as requested and include: (a) Where appropriate, a plan for personal wellness and resilience, including relapse prevention; (b) Identification of resources to assist the individual and family, if applicable, in accessing recovery and resiliency services and supports; (c) Referrals to follow up services and other behavioral health providers; and (d) When services are transferred due to the absence of the individual, the provider shall document outreach efforts made to re-engage the individual or document the reason why such efforts were not made. (5) To the extent permitted or required by applicable confidentiality laws, when the transfer summary of treatment services is sent to another provider or level of care, it shall be sent in advance of the individual’s entry into services at another provider or the next level of care. To the extent permitted by law, all other documentation contained in the Service Record that is requested by the receiving provider shall be furnished, within 14 days of receipt of a written request for the documentation. Statutory/Other Authority: ORS 413.042, 428.205 - 428.270, 430.640 & 443.450 Statutes/Other Implemented: ORS 430.010, 430.205 - 430.210, 430.254 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991, 461.549 & 743A.168 History: BHS 10-2023, amend filed 04/07/2023, effective 04/07/2023 MHS 4-2018, amend filed 02/27/2018, effective 03/01/2018 MHS 10-2017(Temp), f. 9-15-17, cert. ef. 9-15-17 thru 3-13-18 MHS 3-2014, f. & cert. ef. 2-3-14 MHS 10-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14