Best Practices Discharge Planning Manual FINAL

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Discharge Planning Manual 2,Table of Contents,Foreword 4. Executive Summary 6, Chapter 1 Discharge Planning for Mental Health Substance Abuse and Co Occurring MH and SA. Introduction 8,Scope of Problem Data Elements 9,Mental Health 9. Substance Abuse 10,Scope of Problem in Los Angeles County 12. Value of Conducting Discharge Planning 14,Discharge Planning Model 15.
Who Should be Involved in Discharge Planning 16,Elements of Successful Discharge Planning 16. Examples of Model Programs 19,Recommendation for Providers 20. Chapter 2 Hospital Discharge Planning,Introduction 21. Scope of Problem Data Elements 22,Scope of Problem in Los Angeles County 22. Value of Conducting Discharge Planning 26,Discharge Planning Model 27.
Who Should be Involved in Discharge Planning 28,Elements of Successful Discharge Planning 29. Examples of Model Programs 30,Implications 32,Recommendations for Providers 35. Building a Perfect Model 36,Barriers 36,Chapter 3 Foster Care Discharge Planning. Introduction 37,Scope of Problem Data Elements 38,National 38. California 38,Challenge Cycle of Services 38,Challenge Housing and Homelessness 39.
Challenge LGBTQ Concerns 40,Scope of Problem in Los Angeles County 41. August 2008,Value of Conducting Discharge Planning 42. Discharge Planning Model 43,Who Should be Involved in Discharge Planning 44. Elements of Successful Discharge Planning 45,Examples of Model Programs 47. Recommendations for Providers 47,Discharge Planning Manual 3.
Chapter 4 Discharge Planning for Prisons and Jails. Introduction 48,Scope of Problem Data Elements 49,Scope of Problem in Los Angeles County 50. Value of Conducting Discharge Planning 52,Discharge Planning Model 53. Who Should be Involved in Discharge Planning 53,Elements of Successful Discharge Planning 54. Examples of Model Programs 55,Recommendations for Providers 56. Appendix A Mental Health Template of Discharge Plan 58. Appendix B Mental Health Discharge Plan Checklist 63. Appendix C Hospitals KFH Regional Protocol on Homeless Discharge Planning 64. Appendix D Hospitals California Discharge Plan Laws 68. Appendix E Foster Youth Discharge Plan Checklist 72. Appendix F Foster Youth Exemplary Discharge Plan 74. Appendix G Foster Youth It s My Life Logic Model 75. Appendix H Prison and Jails Program Contact Information 76. Appendix I Prison and Jails West Virginia Division of Corrections Appendix 77. Annotated Bibliography,General 84,Mental Health and Substance Abuse 97.
Hospitals and Health Care 109,Foster Youth 125,Prisons and Jails 134. August 2008,Discharge Planning Manual 4,A significant majority of the homeless. population in California and specifically Los,Angeles County are individuals who have. recently been discharged from an institution or,care facility Specifically according to the Los. Angeles based Economic Roundtable 60 of,homeless individuals and over 50 of families.
self report that they were discharged into,homelessness either by a shelter jail hospital. or other care facility These individuals have,been admitted to a system that has poor and. inadequate planning for their release Consequently they are discharged to the. streets either returned to homelessness or become homeless and their health and. stability soon begins to deteriorate According to the U S Interagency Council on. Homelessness Institutional discharge is the process to prepare a person for return or. reentry to the community by connecting the individual to essential community treatment. housing and human services 1, The U S Interagency Council on Homelessness found in their 1994 report Priority. Home that persons with low income and persons of color are more likely to. experience homelessness upon departure from a hospital treatment facility penal. institution or the foster care system 2,These systems all lack comprehensive planning. strategies which result in an increased likelihood. that individuals exiting the system will become,homeless Equipped with little or no tools to.
ensure their successful reentry they often,become overwhelmed and have difficulty. maintaining the gains made throughout treatment,and placement. August 2008, Interagency Council on Homelessness IHC Priority Home The Federal Plan to Break the Cycle of Homelessness 1994. Institutional Discharge Policy Statement National Health Care for the Homeless Council 2008. Discharge Planning Manual 5, The National Health Care for the Homeless Council outlined six recommendations for. providers of mental health health penal institutions and foster care for the successful. implementation of discharge and aftercare planning. 1 The plan should prevent consumers from falling into homelessness. 2 Identification of appropriate housing is critical. Discharges to emergency shelters are inappropriate for any situation. Discharges to homeless programs that have 24 hour transitional. programs may be made on a case by case basis, Discharges to supportive housing and or halfway houses are beneficial.
3 Planning must be individualized comprehensive and coordinated with. community based services,4 Consumers must participate in the planning. 5 Institution staff inclusive of professional staff and community partners should. be included, 6 For consumers who abuse substances appropriate treatment must be. As important as it is to institute these recommendations as well as those detailed in this. manual it is even more important to in the short term advocate for more respite. facilities for homeless people in your community and in the longer term advocate for. affordable housing in your community Discharging people to the streets would not be. an issue if there was enough permanent supportive housing and other affordable. housing models for discharge planners to send their patients to. The following chapters will discuss best practices for discharge planning in four of the. institutions with severe shortcomings in Los Angeles mental health and co occurring. disorder treatment facilities hospitals foster care and jails prisons. The chapters will include data on the scope of the problem in Los Angeles County the. value of conducting discharge planning the elements to be included in planning and. will conclude with recommendations for providers,August 2008. Discharge Planning Manual 6,Executive Summary, This manual presents the best practices in discharge planning with a focus on mental. health and substance abuse facilities hospitals jails and prisons and the foster care. system It is not an end all solution to ending homelessness nor is it the ultimate guide. for discharge planning, There is only one thing that can end homelessness and that is to prevent it and to.
prevent people from being discharged to the streets by the four institutions we will be. discussing, What this manual is however is a guide for discharge planners and administrators to. effectively create and implement discharge plans It does not offer answers to every. situation or work to eliminate the crisis of homelessness. It is a guide that will help you plan and implement effective discharge planning. procedures in an effort to prevent your population from becoming homeless This. manual scratches the surface of the homeless crisis but it is up to you the provider to. advocate for homelessness prevention, One of the biggest problems with discharge planning is that there is simply no where to. discharge inmates foster youth and the mentally physically ill to There is an affordable. housing crisis in Los Angeles and the nation in general and a need to increase funding. for supportive transitional and affordable housing Again part of the uphill battle for. discharge planners is finding somewhere for people to go other than the streets or. emergency shelters, Without adequate affordable housing and supportive places for people to go there lies. a huge crisis who will bear the burden of discharge planning Hospitals have. continuously argued that without these supportive services their hands are tied and. they often have no choice but to dump patients Author Dr Michael Cousineau has. often criticized policy makers and the government for their lack of effort in regards to. providing housing for the homeless He is very critical of policy makers and believes that. many of the cases we are now seeing against hospitals that dump and providers who. do not discharge plan are nothing more than distractions from the underlying problem. August 2008, the government has failed to provide for its homeless and needy Policy makers need to. be responsible for insuring housing and placements are available to those being. discharged but the responsibility for advocating and demanding such locations is a. shared responsibility between all of us,Discharge Planning Manual 7.
Los Angeles City is a tale of 2 cities One very wealthy and the other of deep poverty. destitution and homelessness Los Angeles City has the largest divide between low. income people and wealthy people than any city in the nation In addition Los Angeles. has the disgrace of being the homeless capital of America with nearly 80 000. homeless people on any given night with approximately half of that figure being in LA. City In fact in 2007 Los Angeles met its housing construction goals building over. 12 000 units of housing Sadly however over 90 of this housing was for people with. incomes of 135 000 and above Los Angeles policymakers clearly have no intention of. addressing the crisis of affordable housing for middle and low income people let alone. preventing and ending homelessness, Finally we need solid working relationships between agencies providing services and. housing and the institutions doing the releasing so that all our discharge efforts are. more effective For Los Angeles that means a partnership between Los Angeles City. and Los Angeles County who historically would rather sue or ignore each other than. partner on projects that combine affordable housing LA City with the services people. need LA County, Whether this means shuffling around the money already allocated to such programs to. work more effectively together or creating an entirely new plan creating new. relationships and partnerships and a collective effort are essential. Special thanks to members of our focus group Paul Freese of Public Counsel. Casey Horan the Executive Director of LAMP Community and Dr Jacqueline. McCroskey Professor School of Social Work University of Southern California. This manual was funded by a grant from The California Endowment. August 2008,Discharge Planning Manual 8,Chapter One Discharge Planning for. Mental Health and Substance Abuse Facilities, There is ample evidence that mental health substance abuse and co occurring i e. substance abuse and mental health providers are doing a poor job of planning for the. discharge of clients from their system of care into that of others This problem is not. unique to the mental health and substance abuse treatment fields as discharge planning. seems to be poorly planned and executed in multiple systems of care Highlighted by. Sowers and Rohland fragmentation in systems of care has been common and the. transition from one provider location or intensity of services to another has not been. prioritized in treatment planning 3 For individuals with co occurring disorders the. problem of poor discharge planning and ensuing difficulties are aggravated as they are. dealing with more than one health issue, Either way clients are the ones that suffer as they experience fragmentation.
discontinuity of care and a lack of communication and coordination among the various. services that they may require in the community Ultimately poor discharge planning. negatively impacts any health gains the client may have experienced while in care and. leads to a revolving door phenomenon which is discouraging both to providers and. clients alike, In principle most agree that discharge planning is an important element of care and a. critical activity in the delivery of continuity of care for all clients As providers we want to. feel that our programs and services are having their intended impact of improving the. health status of our clients What appears to be lacking is a common understanding of. discharge planning that is appropriate for clients dealing with substance abuse mental. health and co occurring issues as well as uniform principles and guidelines for. implementation, The following sections present information in regards to the scope of the problem value. of conducting discharge planning models of discharge planning elements and. guidelines in terms of who needs to be involved in discharge planning. recommendations for providers and will provide examples of model programs. Appendices A and B include a template of a discharge plan and a discharge plan. August 2008, Sowers WE Rohland B American Association of Community Psychiatrists Principles for Managing Transitions in Behavioral Health Services. Psychiatric Services http ps psychiatryonline org November 2004 Vol 55 No 11. Discharge Planning Manual 9,Scope of Problem Data Elements. Mental Health An estimated 26 2 percent approximately 57 7 million of. Americans ages 18 and older about one in four adults suffer from a diagnosable. August 2008 Discharge Planning Manual 5 The National Health Care for the Homeless Council outlined six recommendations for providers of mental health health

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