309-022-0180 Transfer and Continuity of Care (1) Providers shall meet the following requirements for planned transfer: (a) Decisions to transfer individuals shall be documented in a transfer summary. The documentation shall include the reason for the transfer; (b) Planned transfers shall be consistent with the transfer criteria established by the interdisciplinary team and documented in the service plan; (c) Providers may not transfer services unless the interdisciplinary team in consultation with the child's parent or guardian and the next provider agree that the child requires a more or less restrictive level of care; and (d) If the determination is made to admit the child to acute care, the provider may not transfer services during the acute care stay unless the interdisciplinary team in consultation with the child's parent or guardian and the next provider agree that the child requires a more or less restrictive level of care following the acute care stay. (2) Prior to transfer providers shall: (a) 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 arrange an initial appointment with that provider; (b) Coordinate recovery and ongoing support services for individuals and their families including identifying resources and facilitating linkage to other service systems necessary to sustain recovery including peer delivered services; (c) Complete a transfer summary; (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; (e) If the individual is under the jurisdiction of the PSRB or JPSRB, the provider shall notify the PSRB or JPSRB immediately and provide a copy of the transfer summary within 30 days; (f) The provider shall report all instances of transfer on the mandated state data system; and (g) At a minimum, the provider's interdisciplinary team shall: (A) Integrate transfer planning into ongoing treatment planning and documentation from the time of entry and specify the transfer criteria that shall indicate resolution of the symptoms and behaviors that justified the entry; (B) Review and, if needed, modify the transfer criteria in the service plan every 30 days; (C) Notify the child's parent or guardian and the provider to which the child shall be transitioned of the anticipated transfer dates at the time of entry and when the service plan is changed; (D) Include the parent or guardian peer support when requested by the parent or guardian and provider to which the child shall be transitioned in transfer planning and reflect their needs and desires to the extent clinically indicated; (E) Finalize the transition plan prior to transfer and identify in the plan the continuum of services and the type and frequency of follow-up contacts recommended by the provider to assist in the child's successful transition to the next appropriate level of care; (F) Assure that appropriate medical care and medication management shall be provided to individuals who leave through a planned transfer. The last service provider’s interdisciplinary team shall identify the medical personnel who provides continuing care and shall arrange an initial appointment with that provider; (G) Coordinate appropriate education services with applicable school district personnel; and (H) Give a written transition plan to the child's parent or guardian and the next provider if applicable on the date of transfer. (3) A transfer summary shall include the following: (a) The date and reason for the transfer; (b) A summary statement that describes the effectiveness of services in assisting the individual and their family to achieve intended outcomes identified in the service plan; (c) Where appropriate, a plan for personal wellness and resilience, including relapse prevention safety and suicide prevention planning; and (d) Identification of resources to assist the individual and family including peer delivered services, if applicable, in accessing recovery and resiliency services and supports; (e) If the transfer is to services with another provider, all documentation contained in the service record requested by the receiving provider shall be furnished, compliant with applicable confidentiality policies and procedures within 14 days of receipt of a written request for the documentation; (f) A complete transfer summary shall be sent to the receiving provider within 30 days of the transfer. Statutory/Other Authority: ORS 161.390, 413.042, 430.256, 426.490 - 426.500, 428.205 - 428.270, 430.640 & 443.45 Statutes/Other Implemented: ORS 109.675, 161.390 - 161.400, 179.505, 413.520 - 413.522, 426.380 - 426.395, 426.490 - 426.500, 430.010, 430.205 - 430.210, 430.240 - 430.640, 430.850 - 430.955, 443.400 - 443.460, 443.991 & 743A.168 History: BHS 24-2018, amend filed 12/27/2018, effective 01/25/2019 BHS 16-2018, temporary amend filed 07/17/2018, effective 08/01/2018 through 01/27/2019 MHS 7-2017, f. & cert. ef. 6-23-17 MHS 27-2016(Temp), f. & cert. ef. 12-29-16 thru 6-26-17 MHS 5-2014, f. & cert. ef. 2-3-14 MHS 8-2013(Temp), f. 8-8-13, cert. ef. 8-9-13 thru 2-5-14