309-021-0190 Transition of Care and Transfer Summary (1) IIBHT is a time limited intervention. Youth/young adults and their families may transition to other services when one of the following situations is present: (a) The youth/young person and their family have successfully reached their established goals and objectives in the Service Plan; or (b) The youth/young person and their family requests a transition to a lower level of care; or (c) The youth/young person transitions to a higher level of care, such as residential treatment; or (d) The youth/young person and their family choose to end treatment or move out of the area (2) IIBHT services may overlap with, but shall not duplicate other services, for continuity of care in the following circumstances: (a) prior to the youth/young adult’s discharge from a higher level of care including residential treatment or inpatient hospitalization; or (b) When a youth/young person is temporarily placed in juvenile detention; or (c) When admitted to a brief inpatient psychiatric hospitalization, subacute, or psychiatric residential treatment stay. (3) At the time of transition from IIBHT, the QMHP will complete the IIBHT Transfer Summary in collaboration with the youth/young person and their family, and at a minimum shall document the following: (a) Final Treatment Review Meeting that includes at a minimum the youth/young person, their family, IIBHT QMHP and their next provider (whenever possible); (b) The date and reason for transition; (c) Successes and strengths of youth/young adult and their family; (d) Review of progress made toward goals and objectives in Service Plan; (e) Review of the current Crisis and Safety Plan; (f) Recommendations for the next level of care, goals, and objectives for ongoing treatment; (g) A brief summary of the frequency and types of services the youth/young person and their family received while enrolled in IIBHT; (h) Any established appointments, including dates, times, and contact information for providers taking over ongoing treatment, when applicable. (4) The IIBHT provider shall administer an OHA-approved outcome measures tool: (a) At the final Treatment Review meeting or any time within 30 calendar days prior to discharge from IIBHT services; and (b) Results from the OHA-approved outcome measurement tool shall be entered into the OHA-approved data system within 30 days of entry. (5) The IIBHT Provider shall provide a copy of the Transfer Summary and the Crisis and Safety Plan to: (a) The youth/young adult and their family, in the most developmentally and culturally appropriate language, prior to the end of services but not more than 14 business days when translation services are required. (b) The next service provider, no later than seven calendar days following the last day of IIBHT services. (c) IIBHT provider shall document in the youth’s service record that these documents were provided and clearly document reasons if they were not. (6) If the IIBHT provider is unable to contact the youth/young person and their family after multiple attempts during at least a two week time period and it is determined that the youth/young person will be disenrolled from IIBHT services without a final Treatment Review meeting and transition planning, the IIBHT provider must document attempts to contact the youth/young person and their family and send a copy of the Transfer Summary and Crisis and Safety Plan to the youth/young person and their family, no later than seven calendar days of closure. Statutory/Other Authority: ORS 413.042, 430.640 & 430.705 Statutes/Other Implemented: ORS 430.010, 430.205 & 430.708 History: BHS 3-2025, adopt filed 02/27/2025, effective 03/01/2025