Discharge Planning And Developing A Plan For Independence

The Friends Connection believes that creating a vision for self-directed success means moving forward in recovery without support of the peer counselor. At this stage in recovery, and for this final goal setting, the program supervisor and the peer counselor assist the person in planning to develop a realistic and idealistic vision for the future.

At the Friends Connection, discharge is a 3-month planning process where the person is encouraged to act more independently utilizing natural and community supports, while the peer support staff decreases contact. At the discharge planning meeting, the person discusses what he or she wants for the future and independent rehabilitation activities are increased in intensity as the person moves closer to discharge.

Readiness is determined by the person's ability to carry out increased independent recovery activities in the community. Necessary resources are identified and secured to assist with development of an independent recovery plan. The person is also invited to participate in the Friends Connection Alumni Program where he or she is connected to other graduates of the program who are stable in recovery. As a graduate of the Friends Connection program the person will be invited to attend alumni meetings, to participate in alumni activities, and to attend Friends Connection ongoing large group community activities.

The person is then asked to work closely with the Peer Counselor and Program Supervisor to prepare a discharge plan. The peer counselor and the person work together, with thoughtfulness and reflection, to identify realistic steps to achieve future goals and to finalize the discharge plan. The plan is reviewed and discussed and a discharge meeting date is established.

Concurrent Review For Discharge And Graduation

• The person identifies, achieves and sustains self-determined goals including a level of functional skills based on his or her specific ethnic or cultural environment.
• The person shows evidence of sustaining social supports and resources identified in the rehabilitation plan and the person readily accesses supports.
• The maximum amount of benefit has been achieved and there is a reasonable expectation that the withdrawal of services will not result in loss of goals attained.
• The person voluntarily decides to leave the program.
• Upon discharge or termination the person is informed of his or her rights.
• Upon discharge or termination the person is informed of the process for appeal.

The Program Supervisor facilitates the discharge process under the direct supervision of the Clinical Manager to assure that the goals and benefits of the program have been maximally achieved. The responsibilities of the Program Supervisor for making determinations regarding discharge include:

• Assuring that a follow-up psychosocial or functional assessment is performed with the person to determine progress, strengths, and continuing needs relevant to recovery.
• Assuring that a determination is made about whether the person continues to have severe or moderate difficulties in functioning or in sustaining goals for recovery.
• Identifying and referring to case management or other programs as appropriate and needed.
• Assuring that aftercare services are planned and coordinated.
• Determining whether there is a reasonable expectation that withdrawal of services may result in a loss of rehabilitation gains or goals or a recurrence of symptoms.
• Determining whether the person agrees to continue participation in the program as part of the graduate or alumni program.
• Determining whether the person agrees to being discharged from the program.
• Completion of continued stay review and all discharge documentation.

Discharge Information

Program participants may be discharged from the Friends Connection program for the following reasons:

• Medical Necessity (participant successfully attains goals as defined in Personal Goal Plan).
• Inability to engage/locate program participant.
• Long-term inpatient hospitalization (psychiatric or residential rehab) which impedes participation in the Friends Connection.
• Program participant requests discharge from services.