Date
of Last Review 10/13/08
SME: Director of Social Services
Discharge and aftercare planning begins on the day of admission and continues
throughout a patient's stay.
Discharge planning is an interdisciplinary activity as follows:
 | The attending physician leads the discharge planning |
| The Social Service clinician has the responsibility for the discharge and aftercare arrangements |
| The treatment team under MD leadership and orders decides the following: |
 | The date of discharge |
| The type of aftercare treatment |
| Other arrangements that will best meet the patient's needs. |
The Discharge plan focuses on the following:
| Ongoing psychiatric and medical treatment |
| Residence |
| Personal support network |
| Vocational and educational resources |
| Transportation to residence upon discharge |
| Transportation for ongoing treatment |
Ongoing psychiatric treatment alternatives can be provided by one of the following:
| UT-Harris County Psychiatric Center's Continuum of Care |
| The University of Texas Mental Sciences Institute |
| Facilities operated by Texas Department of Mental Health/Mental Retardation |
| The Mental Health/Mental Retardation Authorities of Harris and surrounding counties |
| Private Residential Treatment facilities |
| Physicians or clinics |
When MHMRA is going to provide ongoing psychiatric treatment, a caseworker from the MHMRA Continuity of Care works with the Social Service clinician in developing such plans. The UTHCPC Social Service clinician assigned to the patient is responsible for initiating referrals to Continuity of Care and for acting as liaison after the referral.
Residential alternatives for patients include but are not limited to the following:
| Independent living arrangements |
| Living with family or significant other |
| Placement in licensed assisted living facilities, halfway houses, residential treatment facilities or other supervised care |
| Transfer to a State facility for extended treatment |
Personal support alternatives include but are not limited to the following:
| Patient's family of origin or nuclear family |
| Significant others |
| Twelve step and other support groups |
Discharge planning is discussed in weekly meetings with the Juvenile Probation department as follows:
| If the patient is returning home, the usual procedure is followed for aftercare and placement |
| If the patient is to return to the Juvenile Probation System on a residential basis, then the final decision as to aftercare and placement is rendered by a Judge or Chief Juvenile Probation Officer |
| These decisions involve the recommendations of the treatment team and the assigned Juvenile Probation Officer |
Related to regulatory standards JCAHO PC.5.50
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