Training Center Discharge Planning and Discharge

Discharge Planning and Discharge Plans

1.   Discharge planning shall begin upon admission.

2.   Discharge planning shall drive treatment of individuals in any Training Center and shall adhere to the principles of person-centered planning.

3.   Individuals in Training Centers shall participate in their treatment and discharge planning to the maximum extent practicable, regardless of whether they have Authorized Representatives. Individuals shall be provided the necessary support (including, but not limited to, communication supports) to ensure that they have a meaningful role in the process.

4.   The goal of treatment and discharge planning shall be to assist the individual in achieving outcomes that promote the individual’s growth, well being, and independence, based on the individual’s strengths, needs, goals, and preferences, in the most integrated settings in all domains of the individual’s life (including community living, activities, employment, education, recreation, healthcare, and relationships).

5.   The Commonwealth shall ensure that discharge plans are developed for all individuals in its Training Centers through a documented person-centered planning and implementation process and consistent with the terms of this Section. The discharge plan shall be an individualized support plan for transition into the most integrated setting consistent with informed individual choice and needs and shall be implemented accordingly. The final discharge plan (developed within 30 days prior to discharge) will include:

a.    Provision of reliable information to the individual and, where applicable, the Authorized Representative, regarding community options in accordance with Section IV.B.9;

b.    Identification of the individual’s strengths, preferences, needs(clinical and support), and desired outcomes;

c.    Assessment of the specific supports and services that build on the individual’s strengths and preferences to meet the individual’s needs and achieve desired outcomes, regardless of whether those services and supports are currently available;

d.    Listing of specific providers that can provide the identified supports and services that build on the individual’s strengths and preferences to meet the individual’s needs and achieve desired outcomes;

e.    Documentation of barriers preventing the individual from transitioning to a more integrated setting and a plan for addressing those barriers.

                                             i.        Such barriers shall not include the individual’s disability or the severity of the disability.

                                            ii.        For individuals with a history of re-admission or crises, the factors that led to re-admission or crises shall be identified and addressed.

6.   Discharge planning will be done by the individual’s PST. The PST includes the individual receiving services, the Authorized Representative (if any), CSB case manager, Training Center staff, and persons whom the individual has freely chosen or requested to participate (including but not limited to family members and close friends). Through a person-centered planning process, the PST will assess an individual’s treatment, training, and habilitation needs and make recommendations for services, including recommendations of how the individual can be best served.

7.   Discharge planning shall be based on the presumption that, with sufficient supports and services, all individuals (including individuals with complex behavioral and/or medical needs) can live in an integrated setting.

8.   For individuals admitted to a Training Center after the date this Agreement is signed by both parties, the Commonwealth shall ensure that a discharge plan is developed as described hereinwithin30 days of admission. For all individuals residing in a Training Center on the date that this Agreement is signed by both parties, the Commonwealth shall ensure that a discharge plan is developed as described herein within six months of the effective date of this Agreement.

9.   In developing discharge plans, PSTs, in collaboration with the CSB case manager, shall provide to individuals and, where applicable, their Authorized Representatives, specific options for types of community placements, services, and supports based on the discharge plan as described above, and the opportunity to discuss and meaningfully consider those options.

a.    The individual shall be offered a choice of providers consistent with the individual’s identified needs and preferences.

b.    PSTs and the CSB case manager shall coordinate with the specific type of community providers identified in the discharge plan as providing appropriate community-based services for the individual, to provide individuals, their families, and, where applicable, their Authorized Representative with opportunities to speak with those providers, visit community placements (including, where feasible, for overnight visits) and programs, and facilitate conversations and meetings with individuals currently living in the community and their families, before being asked to make a choice regarding options. The Commonwealth shall develop family-to-family and peer programs to facilitate these opportunities.

c.    PSTs and the CSB case managers shall assist the individual and, where applicable, their Authorized Representative in choosing a provider after providing the opportunities described above and ensure that providers are timely identified and engaged in preparing for the individual’s transition.

10.Nothing in this Agreement shall prevent the Commonwealth from closing its Training Centers or transferring residents from one Training Center to another, provided that, in accordance with Virginia Code 37.2-837(A)(3), for as long as it remains effective, no resident of a Training Center shall be discharged from a Training Center to a setting other than a Training Center if he or his Authorized Representative chooses to continue receiving services in a Training Center. If the General Assembly repeals Virginia Code 37.2-837(A)(3), the Commonwealth shall immediately notify the Court, the United States, and the Intervenors. The Parties agree that repeal or alteration of Virginia Code 37.2-837(A)(3) justifies consideration of relief under Fed. R. Civ. P 60(b)(6).

11.The Commonwealth shall ensure that Training Center PSTs have sufficient knowledge about community services and supports to: propose appropriate options about how an individual’s needs could be met in a more integrated setting; present individuals and their families with specific options for community placements, services, and supports; and, together with providers, answer individuals’ and families’ questions about community living.

a.    In collaboration with the CSBs and community providers, the Commonwealth shall develop and provide training and information for Training Center staff about the provisions of this Agreement, staff obligations under the Agreement, current community living options, the principles of person-centered planning, and any related departmental instructions. The training will be provided to all applicable disciplines and all PSTs.

b.    Person-centered thinking training will occur during initial orientation and through annual refresher courses. Competency will be determined through documented observation of PST meetings and through the use of person-centered thinking coaches and mentors. Each Training Center will have designated coaches who receive additional training. The coaches will provide guidance to PSTs to ensure implementation of the person-centered tools and skills. Coaches throughout the state will have regular and structured sessions with person-centered thinking mentors. These sessions will be designed to foster additional skill development and ensure implementation of person-centered thinking practices throughout all levels of the Training Centers.

12.In the event that an individual or, where applicable, Authorized Representative opposes the PST’s proposed options for placement in a more integrated setting after being provided the information and opportunities described in Section IV.B.9, the Commonwealth shall ensure that PSTs:

a.    Identify and seek to resolve the concerns of individuals and/or their Authorized Representatives with regard to community placement;

b.    Develop and implement individualized strategies to address concerns and objections to community placement; and

c.    Document the steps taken to resolve the concerns of individuals and/or their Authorized Representatives and provide information about community placement.

13.All individuals in the Training Center shall be provided opportunities for engaging in community activities to the fullest extent practicable, consistent with their identified needs and preferences, even if the individual does not yet have a discharge plan for transitioning to the community.

14.The State shall ensure that information about barriers to discharge from involved providers, CSB case managers, Regional Support Teams, Community Integration Managers, and individuals’ ISPs is collected from the Training Centers and is aggregated and analyzed for ongoing quality improvement, discharge planning, and development of community-based services.

15.In the event that a PST makes a recommendation to maintain placement at a Training Center or to place an individual in a nursing home or congregate setting with five or more individuals, the decision shall be documented, and the PST shall identify the barriers to placement in a more integrated setting and describe in the discharge plan the steps the team will take to address the barriers. The case shall be referred to the Community Integration Manager and Regional Support Team in accordance with Sections IV.D.2.a and f and IV.D.3 below, and such placements shall only occur as permitted by Section IV.C.6.