Planning for Transition and Discharge, Part 2

“In the world through which I travel, I am endlessly creating myself." - Frantz Fanon

A transition plan should be written as the patient is preparing to no longer be involved in intensive treatment and will be receiving only supportive counseling, even though the person has not been formally discharged and remains on the caseload of those receiving services from the treatment facility. In other words, the plan should be prepared whenever a person’s major active involvement in the treatment services changes or ends. Ideally, as the person reduces their involvement with the treatment agency and transitions to more time in the community, their plan becomes more complex and self help focused. The treatment plan leads to the transition plan. Many of the themes evident during treatment are naturally carried forward into the individual’s life in recovery in the community.

Transition from treatment to community support or simply a step down in treatment frequency can be a time of increased pressure and intense adjustment for the patient. Creating a safety net in whatever form possible is essential. A thoughtfully crafted written transition plan can assist the individual to continue healthy habits and take advantage of resources to support and enhance their recovery. As with treatment planning, collaboration with the patient is essential.

When writing the plan, focus on the positive: have the individual visualize wellness for themselves. What does it look like, feel like, sound like? What are the needed steps to get there? Generally, staying sober is a key foundation for all the other goals. Use their “recovery capital” – what are their strengths in the various life domains? If they have an interest and skills in computers, for example, how can that be used to their advantage?

An effective transition plan should contain concrete, practical suggestions and strategies. “Go to the doctor” is open to interpretation. More useful is “Go to Dr. Jones for a follow up physical on May 10th at 2 pm," including Dr. Jones’ location and contact information. Encourage patients to establish a routine that includes regular times and places for activities, particularly for activities that they enjoy. Help individuals to learn to practice behavior like mindful breathing and mindful walking and then write the practice on the plan as a regular activity. Include recovery maintenance tricks like deep breathing and responses to triggers such as AA slogans, saying the Serenity Prayer or other quick “fixes” that work for the individual.

The written transition plan includes referrals and a provision for forwarding information as appropriate. Relapse prevention plans should be an integral part of the transition plan. Terry Gorski writes “Preparation is often the key to succeeding in anything we pursue, including relapse prevention. We know that relapse is often part of recovery. Although not everyone relapses, those that do relapse can mitigate the destruction with a well constructed and prepared relapse prevention plan. Relapse prevention planning can mean the difference between a short term relapse with minimal consequences, and losing everything in a long term bout with your addiction.”

It is important to include the input and participation of the patient, the family, personnel and the referral source, as appropriate, in the transition plan. The plan should take into account the strengths, abilities, needs, and preferences (SNAP) of the patient, as well as their established and preferences and achieved expectations. Of course, the original plan should be kept by the patient and a copy of the plan retained in the patient record. Individuals who participate in the development of the transition plan could receive a copy of the plan, if appropriate and permitted.

Excerpted from Patient Records and Addiction Treatment, 4th Edition