Continuing Care Plan and Discharge

Section 2060.480  Continuing Care Plan and Discharge a)         Organizations shall develop a continuing care plan with input from the patient and, if possible, prior to discharge for any patient no longer meeting the criteria for continued active treatment at that organization.  The continuing care plan shall contain the following information as appropriate for each individual patient: 1)         Strategies to avoid a recurrence of problematic substance use that also identifies actions to re-engage in treatment should this occur; 2)         Activities planned by the organization to support continued recovery; 3)         Specific and measurable patient involvement if accountability by the patient is required for any case management or monitoring organization (e.g., courts, probation offices, the Illinois Secretary of State, parole officers, employers, the Illinois Department of Children and Family Services, etc.); and 4)         If not already provided, identification of community and recovery support services that can help to maintain, support, and enhance progress made in treatment and the patient's recovery capital, including referrals for stable housing, if needed. b)         Organizations shall develop discharge and exclusionary criteria consistent with customary clinical standards.  All patients shall be informed of the criteria at intake, as specified in Section 2060.430. c)         Upon completion of treatment services from the organization, a discharge summary shall be completed for each patient within 15 calendar days after discharge.  The most recent continued service review can be substituted for the discharge summary; however, in both cases, the document shall contain the following: 1)         The reason for discharge; 2)         Progress of the patient relative to each goal and objective in the treatment plan; 3)         An assessment statement of the patient's condition at discharge, including any continued use of prescribed medication; and 4)         The patient's continuing care plan. d)         If possible, a copy of the discharge summary and continuing care plan should be provided to the patient upon discharge but, in all cases, made available to the patient upon request.