Inpatient Clinical Pathway for Children with
Behavioral Health Discharge Disposition

 
 
 
 
  • 24-48 hours after social work/BHIP consult, schedule family meeting
    • Include medical team/BHIP/unit social work
    • Discuss discharge care options using mutual decision making
    • Review Medical Clearance evaluation, timing
 
 
Level of Discharge Care Recommendations
As determined by Social Work and/or BHIP
 
 
 
 
 
 
Low Acuity Discharge Care
  • Outpatient Services
  • Crisis Mobile Intensive Services
  • Intensive Outpatient
  • Partial Hospitalization
  • Blended Case Management
  • Behavioral Health Rehabilitation
  • Family Based Services
High Acuity Discharge Care
  • Acute Inpatient Hospitalization
  • Crisis Stabilization Unit
  • Psychiatry completes 201/302
    • Consent for treatment/transfer
 
 
 
 
 
 
Initiate Discharge Process
  • Medical team confirms medical clearance and medical discharge plan
  • Social Work/BHIP confirms BH Discharge Care Plan
  • Medical Clearance completed
  • Please document the following:
    • Patient is medically cleared, awaiting BH disposition planning
 
 
 
 
 
 
Low Acuity Discharge Actions
  • Medical Team
  • Schedule PCP follow-up appointment for patient
    • If CHOP PCP, EPIC note to PCP
  • Discharge patient

  • Nursing
  • Prepare and review discharge instructions with patient/family
  • Obtain discharge consent
  • Return medications and/or belongings

  • Unit Social Work
  • Meets with patient/family
  • Provides education for discharge planning
  • Provides outpatient BH resources or refers case to social work BH disposition coordinator, as appropriate

  • Social Work Coordinator
  • Schedule BH outpatient appointment, as requested by Medical
    • Team/BHIP
  • Review with patient/family
    • BH appointment time, location
    • Provide list of resources, at request of BHIP
  • Re-contacts patient/family after appointment
Intermediate Acuity Discharge Actions
  • Medical Team
  • Schedule PCP follow-up appointment for patient
    • If CHOP PCP, EPIC note to PCP
  • Discharge patient

  • Nursing
  • Prepare and review discharge instructions with patient/family
  • Obtain discharge consent
  • Return medications and/or belongings

  • Unit Social Work
  • Meets with patient/family
  • Provides education for discharge planning
  • Refers case to social work BH disposition coordinator

  • Social Work Coordinator
  • Refer patient to recommended BH program
  • Complete referral packet
  • Assures insurance pre-authorization
  • Secure intake date for patient/family
  • Follow-up call day after discharge & day after scheduled appointment
  • Confirm patient/family BH plan
  • Additional resources, if necessary
  • Medical Team
  • Document medical clearance/stability
  • Weekdays
    • Refers case to unit social work
  • Weekends
    • Refers case to on-call social work

  • Nursing
  • Confirm original 201/302 in chart
    • Inpatient clerk to copy chart and place original 201/302 with the copied chart
  • If notified by social work, complete RN to RN handoff through transport
  • In discharge instructions, include interagency transfer note
  • Complete transport checklist

  • Unit Social Work
  • Meets with patient/family to confirm discharge plan
  • Provides education for discharge planning
  • Refers case to social work BH disposition coordinator

  • Care coordination between Primary Care Team and BH disposition team
  • Social Work Coordinator
  • Review options for placement with patient/family
  • Completes insurance pre-authorization
  • Confirm 201/302 completed and in physical chart
  • Fax psychiatry assessment to appropriate facilities
  • Escalation Plan
    (If needed due to placement difficulty)
  • Facility accepts patient for transfer
  • Patient/family and medical team informed
  • CHOP transport, 42160
  • Transport department completes transfer

  • *Transfers other than acute inpatient psychiatric placement are completed by family members, children youth services, or community agencies
Posted: May 2020
Revised: June 2022
Authors: T. Chen, MD; E. Perry, LCSW; J. Pletcher, MD; K. White, LCSW; B. Waiters, LSW; S. Simon, MSN; L. Morrow, PsyD; E. Steinmiller, MD; J. Lavelle, MD; A. Fillmore, BSW