Policy & Procedure
Policy #: BH-202
File Name: Discharge from Substance
Abuse Treatment and
Aftercare
Manual Section: BH-200
Attachments/Forms:
Policy Effective: 05/239/2016
Policy/Board Approved: 05/23/2016
Policy/Board Quality Approved
Internal Quality Review:
Department Responsible: Behavioral Health
Board Officer: ____________________________________
Pete Bergeron, Chairman
POLICY
It is the policy of all Western Wayne Family Health Centers (WWFHC) to prepare clients for
discharge from substance abuse treatment as appropriate, and to document discharge and
aftercare planning. Patients can be discharged when they have successfully completed treatment
or for reasons such as non-compliance with treatment plans or if they pose a threat to staff or
other patients at WWFHC.
PROCEDURE
Patients participating in substance abuse treatment at WWFHC are considered appropriate for
discharge for these reasons:
1. Discharge with improvement:
 Client has successfully completed the treatment program to which he/she originally
agreed, showing that he/she has made significant progress toward treatment goals
 Client demonstrates that he/she can function effectively relative to the original
presenting issue independent of the program and/or Medication Assisted Therapy
(MAT)
 Client has received maximum benefit from the treatment program and needs
additional assistance from another resource (to which a referral will be made). This
referral may or may not be directly related to the presenting problem
 As part of aftercare planning, clients are referred to continuing services in the
community
2. Discharge by mutual consent
a. The client and staff agree that he/she should withdraw from the program for any of
the following reasons:
 Client doesn’t wish to continue
 Client needs to withdraw due to medical, legal or family issues, geographic
relocation, or other demands
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There is a consensus of the staff that adequate services for the client cannot be
provided within this setting, and appropriate referrals to other programs will be
made that may meet the client’s needs more effectively
Client is resistant to making meaningful efforts to accomplish his/her treatment
goals and objectives for longer than one month
3. Discharge without improvement
 Client’s lack of attendance and/or motivation prevents further progress toward
achievement of goals
 Client missed more than two treatment appointments with therapist, physician, or care
manager and is automatically discharged
 Client demonstrates inappropriate behavior relative to self, staff or other clients that is
disruptive to treatment process
4. Discharge by administrative action
 Relapse—client uses alcohol or an illicit substance during their treatment, or misuses
prescribed medications
o Upon relapse, the client will be assessed by the clinical team (therapist, case
manager, or physician if on MAT) to determine if the client should remain in
treatment or needs to be referred to another level of care. Clients who need detox
or residential care shall be immediately referred out to the appropriate provider.
Clients who have repeated relapses (two times within 3 weeks for example) will
be referred to higher level of care and their case closed
 Client, if on MAT, does not have positive urine test for prescribed agent
 Client shows continuing resistance in making meaningful efforts toward treatment
goals and objectives
 Client is violent or threatens violence (includes use of inappropriate language and
behaviors, excessive aggression, verbal attacks , and other actions as per CLN 115Dismissal From Care policy)
 Client refuses to make appropriate arrangements to pay fees, if applicable
Unless a client leaves the WWFHC program before his or her course of treatment is completed, a
person shall not be discharged from program while physically dependent upon a drug prescribed
for them by the program physician, unless the client is first given an opportunity to withdraw
from the drug under medical supervision and at a rate determined by the program physician OR
the client is referred to an outside resource which is willing to continue administration of that
drug. The offer to provide withdrawal or referral to another resource shall be made both verbally
and in writing. If the client refuses such an offer, the program shall attempt to secure a signed
statement from the client which verifies that the offer was made to, and was rejected by, the
client. Failing that, a progress note shall be recorded documenting such an attempt.
A discharge summary will be completed on each client at the time of their last visit and entered
into the Electronic Medical Record (EMR). This will include recommendations for aftercare;
any referrals needed for supportive services or programs; condition of client at discharge;
aftercare plan; and overview of care given during treatment. This should be done on date of
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service, and a superbill generated. State rules require this be done within 2 weeks of discharge
date, but WWFHCs policy about chart entry supersedes this.
Discharge and aftercare planning should be started at time of admission to adequately prepare
client for discharge. Early and active involvement of client, family, referral sources (as
appropriate), and other community agencies is required.
Aftercare planning is included in the discharge process. The client’s record should include the
following as documentation of aftercare planning:
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Recommendations of the therapist and medical provider
Determination of what the client is willing to do
Individualized plans (e.g. information for 12 Step or other community based support
groups for their local area)
Objectives of aftercare plan for reasonable period following discharge
A description of services the program will provide during the aftercare period
Procedure the client is to follow in re-establishing contact with the program, especially in
times of crisis
Frequency with which the program will attempt to contact clients for purposes of followup
Notation that copy of aftercare plan was given to client
If program attempts to follow-up with clients to determine their status, and if this attempt is
made for purposes other than determining the disposition of a referral or for research purposes,
such follow-up shall be limited to methods that either ensure client confidentiality or require
formal written consent of the client. Any mailings from program shall NOT be done in
envelopes that state “WWFHC Substance Abuse Treatment Program” but in generic health
center envelopes. Patient requests for method of contact (as recorded in EMR) will be followed.
Any releases of information requested by client must have properly completed release of
information form authorized by patient or legal representative as per WWFHCs policy and
applicable laws and regulations.