Rule 5122-41-05 | Care coordination, transition planning, and continuity of care.
(A) The PRTF coordinates care with other providers during treatment, as part of transition planning and after treatment.
(B) The PRTF recognizes that transition to the community is challenging for the youth and family or caregiver and assures that services and supports are in place to support the youth's successful return to the community.
(C) Individualized transition planning begins within twenty-four hours of admission with a strong focus on family and caregiver education and engagement in the care of youth, and coordination with partnering entities.
(D) The PRTF partners with OhioRISE care coordination to develop discharge plan back into the community that includes consistent collaboration during the youth's PRTF stay.
(E) The PRTF partners with the youth and family to engage and utilize natural community supports as part of transition planning.
(F) The PRTF coordinates with community providers or partners prior to the transition to ensure services are not interrupted.
(G) PRTFs serving youth with co-occurring behavioral health and intellectual or developmental disabilities will coordinate with the department of developmental disabilities assigned regional coach.
(H) The PRTF will make training available to family and community partners, as needed to serve the needs of the youth.
(I) The PRTF is available to community partners, as well as the youth and family or caregiver at least six months post discharge when the youth is transitioned to a community setting, including at least monthly contact with the youth and family or caregiver unless the youth and family or caregiver decline this contact when the PRTF discusses it and offers it as part of discharge planning.
(J) The PRTF provides written documentation to all participants of the transition plan at least forty-eight hours prior to the youth leaving the PRTF with information on how to access additional supports from the PRTF and community providers including contact information and steps necessary to access each provider.
Last updated October 2, 2023 at 8:36 AM
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