Gila River Health Care Corporation
Gila River Health Care Corporation
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Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition


Section 3.17 Transition of Persons

3.17.1 Introduction
3.17.2 Terms
3.17.3 Procedures
3.17.3-A. Transition from child to adult services
3.17.3-B. Transition due to a change of the Behavioral Health Provider or the behavioral health category assignment
3.17.3-C. Transition to ALTCS Program Contractors
3.17.3-D. Transition to CRS Program Contractors
3.17.3-E. Inter-T/RBHA Transfer
3.17.3-F. Transitions of persons receiving court ordered services

3.17.3-G. Transitions of persons being discharged from inpatient settings
3.17.3-H. Transitions of persons receiving behavioral health services from Indian Health Services (IHS)
3.17.4 References  

3.17.1 Introduction
Persons receiving behavioral health services in the Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) system may experience transitions during the course of their care and treatment. Examples of transitions of care include changing service providers, establishing eligibility under Arizona Long Term Care Services (ALTCS), transitioning into adulthood, and moving out of the T/RBHA’s geographic service area. During transitions of care, behavioral health providers must ensure that services are not interrupted and that the person continues to receive needed behavioral health services. Coordination and continuity of care during transitions are essential in maintaining a person’s stability and avoiding relapse or decompensation in functioning.

The intent of this section is to:

  • Identify the situations that require a transition of care;
  • Describe expectations for providers when initiating or accepting a transition of care for an enrolled person; and
  • Identify resources to assist behavioral health providers in supporting a person who is experiencing a transition of care.

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3.17.2 Terms
Definitions for terms are located online at http://www.azdhs.gov/bhs/definitions/index.php. The following terms are referenced in this section:

Behavioral Health Category Assignment

Designated T/RBHA

Home T/RBHA

Independent Living Setting

Institution for Mental Disease (IMD)

Out-of-area service

Residence

Serious Mental Illness (SMI)

Transfer

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3.17.3 Procedures

3.17.3-A. Transition from child to adult services
Planning for the transition into the adult behavioral health system must begin for any child involved in behavioral health care when the child reaches the age of 16. Planning must begin immediately for youth entering behavioral health care who are 16 years or older at the time they enter care. A transition plan that starts with an assessment of self-care and independent living skills, social skills, work and education plans, earning potential and psychiatric stability must be incorporated in the child’s individual service plan (ISP).

What elements should be addressed as part of the child’s transition plan?
Not all children transfer to the adult Serious Mental Illness (SMI) or General Mental Health/Substance Abuse (GMH/SA) system, but for children who do, providers must ensure a smooth transition. In order to accomplish a smooth transition, providers must develop a clear and explicit process and procedure that will ensure and support the delivery of children’s and adult services during the transition period. Providers must ensure that adult system staff attend and are a part of the Child and Family Team (CFT) (during the four to six months prior to the child turning 18) in order to provide information and be part of the service planning, development and coordination effort that needs to take place so the individualized needs of that child can be met on the day they turn 18 years of age.

Some of the elements to be addressed by the CFT and/or Behavioral Health Provider as part of a transition plan include:

  • Identifying the child’s behavioral health needs into adulthood.
  • Identifying personal strengths that will assist the child when he/she transitions to the adult system.
  • Identifying staff that will coordinate services after the child reaches age 18, including any changes in the behavioral health provider, clinical team, guardian or family involvement.
  • Identifying and collaborating with other involved state agencies and stakeholders to jointly establish a behavioral health service plan and prevent duplication of services.
  • Establishing how the transition will be implemented.
  • Planning for where the child will reside upon turning 18 and how he/she will support him/herself. If an SMI eligibility determination is made, consider initiating a referral for housing, if needed.
  • Identifying the need for referrals to and assistance with applications for Supplemental Security Income (SSI), Rehabilitation Services Administration (RSA), SMI eligibility determination, Title XIX and Title XXI eligibility, housing, guardianship, training programs, etc. In addition, the team and/or behavioral health provider should assist in gathering necessary information to expedite these applications/determinations when the time comes to actually apply, including obtaining medical and school records to substantiate these needs. The team and/or behavioral health provider begin to develop a timeline and task list for when appointments are needed.
  • Identifying the need for transportation to appointments and other necessary activities.
  • Identifying special needs that the child may have and/or whether or not the child will require special assistance services.
  • Identifying whether the child has appropriate life skills, social skills and employment or education plans.
  • Taking necessary action if the child is not eligible for Title XIX or Title XXI benefits and/or Social Security Disability Income (SSDI) and is not determined to have a SMI. Identifying supports needed to be in place for a successful transition.
  • Following guidelines established in ADHS/DBHS Clinical and Recovery Practice Protocol, Transition to Adulthood.
  • Meeting the provisions of the JK Settlement Agreement1 and the Arizona 12 Principles.

The services that have been planned, developed and provided for the child can continue to be provided after the child has turned 18 years of age, assuming that continuation of these services is the choice of the young person when he/she reached the age of majority. Providers shall properly encounter and receive payment for the provision of services of staff involved, including adult system staff, according to T/RBHA procedures included in Section 10.0, T/RBHA Specific Requirements (see http://www.azdhs.gov/bhs/provider/index.htm for a listing of T/RBHA provider manuals).

Providers are responsible for the provision of services for Title XIX/XXI eligible members 18 years of age through 20 years of age (who are still a part of the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program) regardless of their designation as SMI or GMH/SA. Services include case management services and all other covered services that the person’s treatment team determines to be needed to meet individualized needs.

What needs to happen during the year before the child transitions to adult services?

  • When a child receiving behavioral health services reaches the age of 17, behavioral health providers must determine whether the child is potentially eligible for services as an adult with a Serious Mental Illness. If so, behavioral health providers must refer the child for an SMI eligibility determination pursuant to Section 3.10, SMI Eligibility Determination.
  • When a child receiving behavioral health services reaches 17 and a half, the CFT and/or the behavioral health provider must:
    • Assist the child and/or family or guardian in applying for potential benefits (e.g., SSI, food stamps, etc.);
    • Assist the child and/or family in applying for Title XIX or Title XXI benefits; if the child and/or family is already eligible, determine if eligibility will continue for the child once he/she turns 18;
    • Address any new authorization requirements for sharing protected health information due to the child turning 18 (as described in Section 4.1, Disclosure of Behavioral Health Information) to ensure that the clinical team can continue to share information;
    • Ensure that the child’s behavioral health category assignment is changed consistent with Section 7.5, Enrollment, Disenrollment and other Data Submission. Once the child’s behavioral health category assignment has been changed, ongoing behavioral health service appointments must be provided according to the timeframes for routine appointments in Section 3.2, Appointment Standards and Timeliness of Services; and
    • Upon turning 18 years of age, if the person is not eligible for services as a person determined to have a Serious Mental Illness or the person has been determined ineligible for Title XIX or Title XXI services, behavioral health providers can continue to provide behavioral health services consistent with Section 3.4, Co-payments.

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3.17.3-B: Transition due to a change of the Behavioral Health Provider or the behavioral health category assignment
Upon changes of a person’s behavioral health provider or behavioral health category assignment, the behavioral health provider must:

  • Review the current individual service plan and, if needed, coordinate the development of a revised individual service plan with the person, clinical team and the receiving behavioral health provider;
  • Ensure that the person’s comprehensive clinical record is transitioned to the receiving behavioral health provider;
  • Ensure the transfer of responsibility for court ordered treatment, if applicable; and
  • Coordinate the transfer of any other relevant information between the behavioral health provider and other provider agencies, if needed.

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3.17.3-C: Transition to ALTCS Program Contractors
This section does not apply to persons enrolled in the Arizona Long Term Care Services/Division of Developmental Disabilities (ALTCS/DDD). ALTCS/DDD eligible persons receive all covered behavioral health services through T/RBHAs and their contracted providers.

Once a person is determined eligible and becomes enrolled with the Arizona Long Term Care Services/Elderly or Physically Disabled (ALTCS/EPD) Program, behavioral health providers must not submit claims or encounters for Title XIX covered services to the T/RBHA. To determine if a person is ALTCS/EPD eligible, call (602) 528-7100.

The behavioral health provider must, however, continue to provide and encounter needed non-Title XIX covered SMI services (e.g. housing) to persons determined to have a Serious Mental Illness.

Behavioral health providers who contract as an ALTCS provider must not submit encounters for an ALTCS/EPD enrolled person to the T/RBHA after a person transfers to ALTCS, but must submit bills/claims for payment to the ALTCS Program Contractor who in turn submits the encounters to AHCCCS.

When a person who has been receiving behavioral health services through the T/RBHA becomes enrolled in the ALTCS Program, the behavioral health provider must:

  • Include the member in transition planning and provide any available information about changes in physician, services, etc.;
  • Ensure that the clinical and fiscal responsibility for Title XIX behavioral health services shifts to the ALTCS Program Contractor;
  • Provide information to the ALTCS Program Contractor regarding the person’s on-going needs for behavioral health services to ensure continuity of care during the transition period;
  • Review the current treatment plan and, if needed, coordinate the development of a revised treatment plan with the clinical team and the receiving ALTCS provider and/or case manager;
  • Transfer responsibility for any court ordered treatment;
  • Coordinate the transfer of records to the ALTCS program contractor; and
  • Provide information as follows:
    • For Title XIX eligible 21-64 year olds, the number of days the person has received services in an Institution for Mental Disease (IMD) in the contract year (July 1 – June 30)
    • For all persons, the number of hours of respite received in the contract year (July 1 – June 30); and
    • Whether there is a signed authorization for the release of information contained in the comprehensive behavioral health record pursuant to Section 4.1, Disclosure of Behavioral Health Information.

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3.17.3-D. Transition to CRS Program Contractors
Once a person is determined eligible and becomes enrolled with the Children’s Rehabilitative Services (CRS) Program, behavioral health providers must submit claims or encounters for Title XIX covered services to the AHCCCS CRS Program Contractor. These claims or encounters must not be submitted to the RBHA.

To determine if a person is CRS eligible, contact the Gila River Intake and Enrollment Manager at (520) 562-3321 ext. 7010 or (602) 528-7100.

The behavioral health provider must, however, continue to provide and encounter needed non-Title XIX covered SMI services (e.g. housing) to persons determined to have a Serious Mental Illness. The behavioral health provider may continue to provide non-Title XIX covered services funded through the SAPT or CMHS Block Grant to persons who meet the Grant’s population requirements (please see Section 3.19, Special Populations) as funding is available.

All restrictions on these funds, and adherence to priority population requirements, as specified in Section 3.19, Special Populations must be applied to this population. The member must be a child/adolescent with a Serious Emotional Disturbance (SED) or an adult with a Serious Mental Illness (SMI) to receive CMHS-funded services; SAPT funds may only be expended on members with a diagnosed Substance Use Disorder.

The RBHA and provider(s) are required to receive prior approval from ADHS for any flex fund expenditures exceeding $1,525.00 per member per contract year (see PM Form 3.13.1, SAPT/CMHS Flex Fund Request).

These non-Title XIX covered services must be encountered to the RBHA. The RBHA must successfully submit a State-Only 834 enrollment for these members prior to encountering for these services.

When a person who has been receiving behavioral health services through the RBHA becomes enrolled in the CRS Program, the behavioral health provider must:

  • Include the member in transition planning and provide any available information about changes in physician, services, etc.;
  • Ensure that the clinical and fiscal responsibility for Title XIX behavioral health services shifts to the CRS Program Contractor;
  • Provide information to the CRS Program Contractor regarding the person’s on-going needs for behavioral health services to ensure continuity of care during the transition period; Review the current treatment plan and, if needed, coordinate the development of a revised treatment plan with the clinical team and the receiving CRS provider and/or case manager; Transfer responsibility for any court ordered treatment;
    • Coordinate the transfer of records to the CRS program contractor; and Provide information as follows:
      • For Title XIX eligible 21-64 year olds, the number of days the person has received services in an Institution for Mental Disease (IMD) in the contract year (October – September 30);
      • For all persons, the number of hours of respite received in the contract year October 1 – September 30); and
      • Whether there is a signed authorization for the release of information contained in the comprehensive behavioral health record pursuant to Section 4.1, Disclosure of Behavioral Health Information.

3.17.3-E Inter-T/RBHA Transfer
How is T/RBHA responsibility determined for adults?
For adults (persons 18 years and older), T/RBHA responsibility is determined by the adult person’s current place of residence, except in the following situation:

  • Persons who are unable to live independently must not be transferred to another T/RBHA with the exception of persons who are unable to live independently but are involved with the DDD. However, T/RBHAs may agree to coordinate an Inter-T/RBHA transfer for individuals unable to live independently on a case-by-case basis. Persons involved with DDD who reside in a supervised setting are the responsibility of the T/RBHA in which the supervised setting is located. This is true regardless of where the adult guardian lives. When an ALTCS/DDD member is placed temporarily in a group home while a permanent placement is being developed in the home T/RBHA service area, covered services remain the responsibility of the home T/RBHA.

How is T/RBHA responsibility determined for children?

  • For children (ages 0-17 years), T/RBHA responsibility is determined by the current place of residence of the child’s parent(s) or legal guardian; and
  • For children who have been adjudicated as dependent by a court, the location of the child’s court of jurisdiction determines which T/RBHA has responsibility.

How is T/RBHA responsibility determined for persons who are temporarily residing in another T/RBHA’s geographic service area (GSA)?
The home T/RBHA remains fiscally responsible for all services provided to an enrolled person who is visiting or otherwise temporarily residing in a different T/RBHA’s geographic service area (GSA) as long as the person, or legal guardian for a child, maintains a place of residence in the home T/RBHA’s GSA and intends to return. If the person, or legal guardian for a child, continues to reside in the new location after 3 months, the provider or T/RBHA may proceed with an Inter-T/RBHA transfer if the person, or legal guardian for a child, is consulted and agrees to the change. Only persons who are able to live independently, with the exception of persons who are unable to live independently but are involved with DDD, can be transferred.

Crisis services must be provided without regard to the person’s enrollment status. When a person presents for crisis services, the T/RBHA or their contracted providers must:

  • Provide needed crisis services;
  • Ascertain the person’s enrollment status with all T/RBHAs and determine whether the person’s residence in the current area is temporary or permanent;
  • If the person is enrolled with another T/RBHA, notify the home T/RBHA within 24 hours of the person’s presentation. The home T/RBHA or their contracted providers is fiscally responsible for crisis services and must:
    • Make arrangements with the T/RBHA at which the person presents to provide needed services, funded by the home T/RBHA;
    • Arrange transportation to return the person to the home T/RBHA area; or
    • Determine if the person intends to live in the new T/RBHA’s geographic service area and if so, initiate a transfer. Persons who are unable to live independently but clearly express an intent/desire to permanently relocate to another service area can be transferred. However, the home T/RBHA must make arrangements for housing and consider this a temporary placement for three months. After three months, if the person continues to clearly express an intent/desire to remain in this new service area, the inter-T/RBHA transfer can proceed.

If the person is not enrolled with any T/RBHA and lives within the service area of the T/RBHA in which the person presented for services, behavioral health providers must notify the T/RBHA to initiate an enrollment. Provider requests to initiate an enrollment with the Gila River RBHA may be made by calling (602) 528-7100.

If the person is not enrolled with any T/RBHA and lives outside of the service area of the T/RBHA at which the person presented for crisis services, the T/RBHA must enroll the person, provide needed crisis services and initiate the inter-T/RBHA transfer. If the person is not enrolled with a T/RBHA, lives outside of the service area in which he/she presents and requires services other than a crisis or urgent response to a hospital, the T/RBHA or their contracted providers must notify the designated T/RBHA associated with the person’s residence within 24 hours of the person’s presentation. The designated T/RBHA must proceed with the person’s enrollment if the person is determined eligible for services. The designated T/RBHA is fiscally responsible for the provision of all medically necessary covered services, including transportation services, for eligible persons.

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What if a T/RBHA or provider receives a referral for a hospitalized person?
In the event that a T/RBHA or provider receives a referral regarding a hospitalized person whose residence is located outside the T/RBHA’s geographic service area, the T/RBHA or provider must immediately coordinate the referral with the person’s designated T/RBHA.

When is an Inter-T/RBHA Transfer required?
An Inter-T/RBHA transfer must be completed under the following circumstances:

  • An adult person voluntarily elects to change his/her place of residence to an independent living setting from one T/RBHA’s area to another. Only adult persons who are able to live independently can be transferred to another T/RBHA, with the exception of persons who are unable to live independently but are involved with DDD. Adult persons involved with DDD who reside in a supervised setting are the responsibility of the T/RBHA in which the supervised setting is located;
  • DDD transfers an adult person who is unable to live independently, but involved with DDD, to another placement;
  • The parent(s) or legal guardian(s) of a child change their place of residence to another T/RBHA’s area; or
  • The court of jurisdiction of a dependent child changes to another T/RBHA’s area. Inter-T/RBHA transfers are not to be initiated when a person is under pre-petition screening or court ordered evaluation (see Section 3.18, Pre-petition Screening, Court Ordered Evaluation and Court Ordered Treatment).

What are the timeframes for initiating an Inter-T/RBHA transfer?
The home T/RBHA or its contracted providers must initiate a referral for an Inter-T/RBHA transfer within the following timeframes:

  • At least 30 days prior to the date on which the person will move to the new area; or
  • If the planned move is in less than 30 days, immediately upon learning of the person’s intent to move.

What are the responsibilities of the receiving T/RBHA during an Inter-T/RBHA transfer?
Within 14 days of receipt of the referral for an Inter-T/RBHA transfer, the receiving T/RBHA or its subcontracted providers must:

  • Schedule a meeting to establish a transition plan for the person. The meeting must include:
    • The person or the person’s guardian or parent, if applicable;
    • Representatives from the home T/RBHA;
    • Representatives from the Arizona State Hospital (AzSH), when applicable;
    • The behavioral health provider and representatives of the CFT/adult clinical team;
    • Other involved agencies; and
    • Any other relevant participant at the person’s request or with the consent of the person’s guardian.
  • Establish a transition plan that includes at least the following:
    • The person’s projected moving date and place of residence;
    • Treatment and support services needed by the person and the timeframe within which the services are needed;
    • A determination of the need to request a change of venue for court ordered treatment and who is responsible for making the request to the court, if applicable;
    • Information to be provided to the person regarding how to access services immediately upon relocation;
    • The enrollment date, time and place at the receiving T/RBHA and the formal date of transfer, if different from the enrollment date;
    • The date and location of the person’s first service appointment in the receiving T/RBHA’s GSA;
    • The individual responsible for coordinating any needed change of health plan enrollment, primary care provider assignment and medication coverage;
    • The person’s behavioral health provider in the receiving T/RBHA’s GSA, including information on how to contact the behavioral health provider;
    • Identification of the person at the receiving T/RBHA who is responsible for coordination of the transfer, if other than the person’s behavioral health provider;
    • Identification of any special authorization required for any recommended service (e.g., non-formulary medications) and the individual who is responsible for obtaining needed authorizations; and
    • If the person is taking medications prescribed for the person’s behavioral health issue, the location and date of the person’s first appointment with a practitioner who can prescribe medications. There must not be a gap in the availability of prescribed medications to the person.

Who is responsible for initiating an Inter-T/RBHA transfer?
The person’s assigned Gila River RBHA Clinician is responsible for initiating Inter-T/RBHA transfers. The Gila River RBHA Clinical Manager or designee is responsible for overall coordination with the referring or receiving RBHA to ensure uninterrupted care to the member.

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What are the Clinical Liaison’s responsibilities during an Inter-T/RBHA transfer?
As part of an Inter-T/RBHA transfer, the behavioral health provider must:

  • Schedule a meeting to establish a transition plan for the person. Include the person in transition planning and provide any available information about changes in physician, services, etc.;
  • Provide information regarding the person’s on-going needs for behavioral health services to ensure continuity of care during the transition period;
  • Review the current treatment plan and, if needed, coordinate the development of a revised treatment plan with the clinical team and the receiving provider;
  • Transfer responsibility for any court ordered treatment;
  • Coordinate the transfer of records to the new behavioral health provider; and
  • Provide information as follows:
    • For Title XIX eligible 21-64 year olds, the number of days the person has received services in an Institution for Mental Disease (IMD) in the contract year (July 1 – June 30);
    • For all persons, the number of hours of respite received in the contract year (July 1 – June 30); and
    • Any signed authorizations for the release of information contained in the person’s comprehensive clinical record pursuant to Section 4.1, Disclosure of Behavioral Health Information.

What are the timeframes for completing an Inter-T/RBHA transfer?
When an Inter-T/RBHA transfer occurs, the person must be disenrolled from the home T/RBHA and enrolled in the receiving T/RBHA contingent upon the date the person expects to relocate to the receiving T/RBHA’s geographic service area, but no later than 30 days of the referral by the home T/RBHA (see Section 7.5, Enrollment, Disenrollment and Other Data Submission). This timeframe allows sufficient time for the receiving T/RBHA to arrange for services and plan the person’s transition. If the person is not located or does not show up for his/her appointment on the date arranged by the T/RBHAs to transfer the person, the T/RBHAs must collaborate to ensure appropriate re-engagement activities occur (see Section 3.8, Outreach, Engagement, Re-Engagement and Closure) and proceed with the inter-T/RBHA transfer, if appropriate.

Who is responsible for care during an Inter-T/RBHA transfer?
In an Inter-T/RBHA transfer, the home T/RBHA and its contracted providers retain responsibility for service provision and coordination of care until such time as a person’s record is closed for that T/RBHA (see Section 3.8, Outreach, Engagement, Re-engagement and Closure). The receiving T/RBHA must not delay the timely processing of an Inter-T/RBHA transfer because of missing or incomplete information.

Courtesy Dosing of Methadone
A person receiving methadone administration services who is not a recipient of take-home medication may receive up to two courtesy doses of methadone from a T/RBHA or its contracted providers while the person is traveling outside of the home T/RBHA area. All incidents of provision of courtesy dosing shall be reported to the home T/RBHA. The home T/RBHA shall reimburse the behavioral health provider providing the courtesy doses upon receipt of properly submitted bills or encounters.

Appeals for Out-of-Area Service Provision
Persons determined to have a Serious Mental Illness who are the subject of a request for out-of-area service provision or Inter-T/RBHA transfer may file an appeal in accordance with Section 5.5, Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI).

Inter-T/RBHA transfers after crisis enrollments
When a person presents for crisis services, providers must first deliver needed behavioral health services and then determine eligibility and T/RBHA enrollment status.  Persons enrolled after a crisis event may not need or want ongoing behavioral health services through the T/RBHA.  Providers must conduct re-engagement efforts as described in PM Section 3.8, Outreach, Engagement, Re-engagement and Closure, however; persons who no longer want or need ongoing behavioral health services must be disenrolled (i.e., closed in the Client Information System) and an inter-T/RBHA transfer must not be initiated.  Persons who will receive ongoing behavioral health services will need to be referred to the appropriate T/RBHA and an inter-T/RBHA transfer initiated, if the person presented for crisis services in a GSA other than where the person resides.

Inter-T/RBHA transfers when persons do not inform the home T/RBHA of a move to another geographic service area (GSA)
Timeframes specified in subsection 3.17.3-E cover circumstances when behavioral health members inform their provider or T/RBHA prior to moving to another service area.  When behavioral health members inform their provider or T/RBHA less than 30 days prior to their move or do not inform their provider or T/RBHA of their move, the designated T/RBHA must not wait for all of the documentation from the previous T/RBHA before scheduling services for the behavioral health member.

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3.17.3-F. Transitions of persons receiving Court Ordered Services
This section pertains to court ordered treatment under A.R.S. § 36, Chapter 5 (see Section 3.18, Pre-petition Screening, Court Ordered Evaluation and Treatment). A person ordered by the court to undergo treatment and who is without a guardian may be transferred from one behavioral health provider to another behavioral health provider, as long as the medical director of the behavioral health provider initiating the transfer has established that:

  • There is no reason to believe that the person will suffer more serious physical harm or serious illness as a result of the transfer;
  • The person is being transitioned to a level and kind of treatment that is more appropriate to the person’s treatment needs; and
  • The medical director of the receiving behavioral health provider has accepted the person for transition.
  • The medical director of the behavioral health provider requesting the transition must have been the provider that the court committed the person to for treatment or have obtained the court’s consent to transition the person to another behavioral health provider as necessary.
  • The medical director of the behavioral health provider requesting the transition must provide notification to the receiving behavioral health provider allowing sufficient time (but no less than 3 days) for the transition to be coordinated between the behavioral health providers. Notification of the request to transition must include:
    • A summary of the person’s needs;
    • A statement that, in the medical director’s judgment, the receiving behavioral health provider can adequately meet the person’s treatment needs;
    • A modification to the individual service plan, if applicable;
    • Documentation of the court’s consent, if applicable; and
    • A written compilation of the person’s treatment needs and suggestions for future treatment by the medical director of the transitioning behavioral health provider to the medical director of the receiving behavioral health provider. The medical director of the receiving behavioral health provider must accept this compilation before the transition can occur.
  • Transportation from the initiating behavioral health provider to the receiving behavioral health provider is the responsibility of the initiating behavioral health provider.

Due to tribal sovereignty, A.R.S. § 36, Chapter 5 does not apply to members of the Gila River Indian Community who may require court ordered evaluation or treatment while residing on-reservation. Court ordered evaluation and treatment procedures for Gila River Indian Community members is prescribed in the Gila River Mental Health Ordinance (GR-06-96). Providers are instructed to contact the Gila River RBHA Clinical Manager for information regarding transitions of court ordered persons

3.17.3-G. Transitions of persons being discharged from inpatient settings

Discharge planning and communication with the Adult Clinical Team or CFT must begin at admission to ensure a smooth transition for behavioral health recipients members being discharged from inpatient settings. Furthermore, re-engagement activities must occur for persons who are discharged from inpatient settings in accordance with Section 3.8, Outreach, Engagement, Re-engagement and Closure. If a behavioral health recipient member will be moving to a GSA other than where he/she has been receiving inpatient treatment services, coordination must occur between T/RBHAs, if applicable, to ensure appropriate services/placement and necessary re-engagement activities occur upon discharge.

All Level I hospitals and residential treatment centers must fax a Med Sheet and Diagnosis to 602-528-1341 or send via a secure (HIPAA compliant, encrypted) email at time of discharge for all Gila River members. Receipt of this information is a prerequisite to obtaining a follow up psychiatric appointment with a Gila River behavioral health medical practitioner.

3.17.3-H. Transitions of persons receiving behavioral health services from Indian Health Services (IHS)

American Indian persons may choose to receive behavioral health services through a RBHA, TRBHA or at an IHS or 638 tribal provider. T/RBHA providers must respond to referrals in accordance with Section 3.3, Referral and Intake Process, and ensure necessary coordination of care occurs.

1The JK Settlement Agreement defines its “Class members” as: all persons, under the age of twenty-one, who are eligible for Title XIX behavioral health services in the State of Arizona and have been identified as needing behavioral health services.

3.17.4 References
The following citations can serve as additional resources for this content area:

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3.17 Transition of Persons
Last Revised: 12/1/2013
Effective Date: 12/1/2013

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