Sec. 10.21.19.07. Discharge and Transitioning

A. Discharge Procedures.

(1) An MTS program may discharge an individual from MTS only when:

(a) The individual:

(i) Is unwilling to continue to accept MTS;

(ii) Is admitted to an inpatient facility for longer than 3 months; or

(iii) Moves from the area served by MTS; or

(b) The Administration's ASO determines that transition and discharge from MTS is medically appropriate.

(2) When an MTS program discharges an individual under §A(1)(a)(i) or (ii) of this regulation, the MTS program shall, as authorized:

(a) Permit the individual to re-enroll in MTS; and

(b) Make assertive efforts to re-enroll the individual.

(3) When an MTS program discharges an individual under §A(1)(a)(iii) of this regulation, the MTS program shall, when possible and as authorized, refer the individual for appropriate mental health and support services in the individual's community.

(4) When transition and discharge from MTS is authorized under §A(1)(b) of this regulation, the MTS treatment coordinator, in collaboration with an individual, shall:

(a) Document the individual's:

(i) Achievement of treatment goals;

(ii) Anticipated needs for treatment and rehabilitation services; and

(iii) Readiness for participation in outpatient mental health clinic (OMHC) or other appropriate outpatient mental health services, as demonstrated by keeping appointments, using transportation independently, obtaining and taking prescribed medications, and actively participating in treatment; and

(b) In consultation with the Administration's ASO, prepare a transition plan, according to the provisions of §B of this regulation.

B. Transition Services. When the Administration's ASO authorizes a transition plan, the individual's treatment coordinator, in consultation with the Administration's ASO, shall:

(1) Arrange transition services in collaboration with:

(a) The individual;

(b) The treatment team;

(c) As appropriate and with proper consent, family members and significant others designated by the individual; and

(d) Designated transition service providers;

(2) Provide authorized MTS transition services, refer the individual for other appropriate services, and arrange to initiate authorized services before a planned discharge;

(3) With proper consent and as authorized by the Administration's ASO, facilitate the individual's transition to other appropriate services by:

(a) Inviting the designated provider or providers of mental health services to whom the individual has been referred to participate in the transition planning;

(b) Forwarding to the provider or providers a copy of the transition and discharge plan; and

(c) For a period of time based on the individual's needs, periodically meeting with the individual and the provider or providers, as necessary to facilitate transition;

(4) If the individual does not successfully complete transition, arrange, if authorized by the Administration's ASO, for the continuation of MTS; and

(5) Complete a discharge summary in accordance with COMAR 10.21.17.07D(3).