Transition_Discharge_and_Aftercare_Planning_Guide.EXHIBIT_B.docx

Transition, Discharge and Aftercare Planning GuideEXHIBIT B

Upon admission

Upon admission or shortly thereafter

3. Upon admission, gather names and contact information for all agencies, local FCFC, medical providers, waiver providers, school personnel, therapist, etc. that are currently involved. Explain to family/custodian that these individuals/agencies will be contacted to be part of the team when the youth is at ViaQuest as well as when the youth transitions to next setting.

· A standard form would be helpful to consistently collect information Also, check the date that IEP and the ISP is due to be updated.

4. As possible, gather releases for records and communication with the individuals/agencies in #3 above.

· A standard release form would be helpful to consistently collect information

Ongoing communication will be vital. Streamline process by obtaining releases when parent/ guardian available.

Upon admission, before or ASAP

6. Develop a list of topics that will be discussed at each team meeting (see item #7 below) with the county of residence team, family and ViaQuest. These can include:

a. Current progress re: behavior and skill development

b. Updates on the strategies, supports and interventions that are effective

c. Medication review

d. Anticipated date of discharge

e. Anticipated environment that the youth will be returning to after discharge (Family home? Respite home? School environment? etc.)

f. Anticipated needs in the environments identified above (in item e.)

g. Additions or changes in home county team members

h. Needed home county team members (if not identified or will be changing)

i. Concerns with current treatment plan or discharge plan

j. During meeting, each team member describes:

· at least one issue or concern with current treatment plan or discharge plan and

· at least one encouraging or positive aspect to current treatment or discharge plan.

NOTE: Creating a standard agenda & designating one team member to take notes electronically so that notes can be distributed to all team members may be helpful

7. Assuming a several months stay, plan regular calls or meetings with the county of residence team and family/custodian to 1) update on progress and 2) begin to discuss what types of services, supports, materials, equipment, staff training, etc. should be in place upon discharge.

If ViaQuest currently has a process in place for ongoing meetings and contacts, begin with this process and modify as needed.

See Item #6 above for suggestions for structure of meeting

8.

9.

10. Prior to discharge, ViaQuest should plan and complete observations and visits to next environments. Examples: Home, school, therapy settings, community settings, respite environments. Information gathered can be used to inform the development of new strategies, environmental supports, or needed professional and family development and support.

· Using a standard observation form can be helpful to assure that important items or considerations are not overlooked. Recording observations on this form can assist in summarizing the visit.

Prior to discharge, youth should have several planned in-person visits to next residence setting (waiver home, family home, etc). Youth should be able to meet new staff & new roommates if applicable.

Observation of the various environments provides valuable information that is often not relayed during a meeting or interview. Information about the environmental task demands and behavioral triggers can be identified. As well as training and resource needs.

If a youth is transitioning to a new residential setting, in-person visits to is critical in successful transition. Seeing the physical structure, meeting with new staff, roommates, etc. Also, visual supports can be helpful with this (pictures of staff, bedroom, living space, etc)

Will depend on length of stay. Would plan to do a visit soon after admission to identify needs that may take time to address. Other visits can be planned based on student need and the baseline observations.

Once setting is determined & is nearing end of stay at ViaQuest, this can begin.

11. Plan for onsite visits/consultations for family/custodian and county of residence team to come to ViaQuest to work with ViaQuest staff to become familiar with:

a. Ziggurat Model

b. Identified supports at each level for the youth

c. How to use supports

d. Positive Behavior support plans

e. Targeted communication supports

f. Supporting Youth with Intensive & Complex Needs Training

g. Other?

NOTE: Developing a standard Technical Assistance/Training form could be helpful way to summarize the information reviewed and as a means of documenting the information covered and the expectation of supports and interventions that will be in place upon the youth’s discharge.

12. When possible, provide family/custodian with schedules, visual supports, strategies, interventions, etc. that have been developed for the youth while at ViaQuest. These familiar items will assist in transition to the next environments as well as an ongoing support.

NOTE: Discharge summary should include resources given to family.

· Develop duplicates of items that cannot be given to family prior to the discharge.

· Provide the supports at discharge

13. IEP and IEP Transition Plan. Prior to discharge it will be wise to suggest an IEP meeting be held with ViaQuest staff and school staff and family/custodian and other relevant team members.

ISP Update. A meeting to update the ISP may also be helpful. If it is not necessary to hold a separate meeting, one meeting for the both plans can be organized and all team members can participate.

IEP may need to be updated, revised or completely changed. Youth age 14 and older are required to have the transition portion of the IEP completed, which includes post school (adult) goals and transition services. This would be the ideal time, before youth leaves ViaQuest, to review and update IEP, transition plan and include the wealth of information that ViaQuest has gathered.

Within the last several weeks of being at ViqQuest.

14. Discuss follow-up plans with the family/cusodian and county of residence team. Provide them with an overview of the follow up activity as well as the purpose of the follow up. Work with the family/cusotdian and team members to select days and times that work for everyone.

Select times and locations where ViaQuest staff will be able to observe if and how supports are being used (If follow up is in-person in home or school).

Provide a written copy of those dates to all team members with a name, email or phone number of how to contact ViaQuest should plans change and the dates are not available.

NOTE: Use a variety of documentation forms when conducting follow up activities. Include a description of the activities, locations, length of time, topics discussed and next steps. Document who is responsible for the next steps and a projected timeline for completion. Provide copies to all involved with the follow up.

15. Develop a summary report for the family/cusotodian and team members at the conclusion of the program. The summary report can include:

a. Youth presenting profile and needs (baseline information)

b. Support plan organized by Zig level

c. Summary of progress data

d. Summary of effective strategies and interventions

e. Names and contact information of the county of residence team that was identified

f. Medications, medication changes, and other biological interventions (i.e. special diet, allergies, medical testing needed, etc.)

g. Resources in the local area- names, contact information

h. Web based resources

i. Suggested ongoing data targets

j. Additional recommendations.

16. After the youth is discharged, for the first 4 week, ViaQuest will participate in weekly meetings with the family/custodian county of residence team & DODD staff. These meetings can be virtual, phone or in person.

Viaquest will be available to the family/custodian & local team should questions regarding strategies & interventions, treatment needs, etc arise.

After 4 weeks, Viaquest will participate in monthly meetings, or mre frequently if needed, to assist with barriers or challenges the family/custodian and county of residence team are facing.

A single document that pulls together a summary of the youth’s needs and builds on youth’s strengths, as well as provides an organized plan is invaluable. It becomes a common document that all can use and reference. The information in this document can also be used to agency specific documents and plans (ISP, IEP, IPE, IP, etc. )

It is critical that ViaQuest remain involved immediately post discharge to assist with addressing any critical issues that may prevent a successful transition.

Use the information summarizing team meetings and youth Progress monitoring as a place to begin.

· Begin completing the summary report the final weeks at ViaQuest.

· Review summary during discharge planning meeting and discuss any needed changes.

· Make any edits from meeting discussion and send final copy to all team members.

Weekly meetings with the family & county of residence team for first four weeks, then at minimum monthly thereafter for remaining two months