SECTION 450:55-25-20. Linkage and transitional care

(a)   The BHH must have procedures and agreements in place to facilitate referral for other medical services needed by consumers beyond the scope of the BHH, as well as to assist the consumer to obtain services that are needed following discharge from the BHH.

(b)   The BHH will also document referrals to community and social support services to facilitate access to formal and informal resources beyond the scope of services covered by SoonerCare, such as those which may be available from other parents, family members, community-based organizations, service providers, grants, social programs, funding options, school-based services, faith based organizations, etc.

(c)   The BHH will develop contracts or memoranda of understandings (MOUs) with regional hospital(s), Psychiatric Residential Treatment Facilities (PRTF) 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 BHH for existing BHH consumers who have been hospitalized or placed in other non-community settings, such as psychiatric residential treatment facilities, as well as to newly identified, potential BHH consumers who are entering the community.

(2)   The BHH team will collaborate with all parties involved including the 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 BHH will document transitional care provided in the clinical records.

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

[Source: Added at 32 Ok Reg 478, eff 1-1-15 (emergency); Added at 32 Ok Reg 2131, eff 9-15-15]