SECTION 450:17-5-183. Care coordination

(a)   Based on a person and family-centered care plan and as appropriate, the facility will coordinate care for the consumer across the spectrum of health services, including access to physical health (both acute and chronic) and behavioral health care, as well as social services, housing, educational systems, and employment opportunities as necessary to facilitate wellness and recovery of the whole person.

(b)   The facility must have procedures and agreements in place to facilitate referral for services needed beyond the scope of the facility. At a minimum, the facility will have agreements establishing care coordination expectations with Federally Qualified Health Centers (FQHCs) and, as applicable, Rural Health Centers (RHCs) to provide healthcare services for consumers who are not already served by a primary healthcare provider.

(c)   The facility must have procedures and agreements in place establishing care coordination expectations with community or regional services, supports and providers including but not limited to:

(1)   Schools;

(2)   OKDHS child welfare;

(3)   Juvenile and criminal justice agencies;

(4)   Department of Veterans Affairs' medical center, independent clinic, drop-in center, or other facility of the Department; and

(5)   Indian Health Service regional treatment centers.

(d)   The facility will develop contracts or memoranda of understandings (MOUs) with regional hospital(s), Emergency Departments, Psychiatric Residential Treatment Facilities (PRTF), ambulatory and medical withdrawal management facilities or other system(s) to ensure a formalized structure for transitional care planning, to include communication of inpatient admissions and discharges of BHH participants.

(1)   Transitional care will be provided by the facility for consumers who have been hospitalized or placed in other non-community settings, such as psychiatric residential treatment facilities. The facility will make and document reasonable attempts to contact all consumers who are discharged from these settings within 24 hours of discharge.

(2)   The facility will collaborate with all parties involved including the discharging/admitting facility, primary care physician, and community providers to ensure a smooth discharge and transition into the community and prevent subsequent re-admission(s).

(3)   Transitional care is not limited to institutional transitions, but applies to all transitions that will occur throughout the development of the enrollee and includes transition from and to school-based services and pediatric services to adult services.

(4)   The facility will document transitional care provided in the clinical records.

(e)   Care coordination activities will be carried out in keeping with the consumer's preferences and needs for care, to the extent possible and in accordance with the consumer's expressed preferences, with the consumer's family/caregiver and other supports identified by the consumer. The facility will work with the consumer in developing a crisis plan with each consumer, such as a Psychiatric Advanced Directive or Wellness Recovery Action Plan.

(f)   Referral documents and releases of information shall comply with applicable privacy and consumer consent requirements.

(g)   Compliance with this Section will be determined by on-site observation, review of organizational documents, contracts, MOUs, and clinical records.

[Source: Added at 33 Ok Reg 964, eff 9-1-16; Amended at 34 Ok Reg 1777, eff 10-1-17]