[6] Transition

• Transition

  • change or modification of current delivery mode to another that is safe and timely to the patient and clinician across all settings.
• Transition can be

  • new mode: f2f to tele, supervised to individualized
  • developmental stages: precursory to school-aged
• Reasons for Transitions

  1. Compensatory strategies have been establish
  2. unwillingness and poor attendance
  3. no measurable benefits due to conditions
• Transition of Compensatory Strategies

  • supervised to individualized
  • generalized across setting
• What should we do for transition of compensatory strategies

  • Reevaluate
  • Gradual decrease of intensity
• We should provide home care plans and reevaluation report for compensatory strategies
• If the patient is unwilling, we should

  • change mode
  • f2f to tele
  • modify or look for program
  • clinician to parent
  • child to clinician
  • refer to other clinician
  • discuss with parents and team
• If the patient is unwilling we should prepare documents such as

  • endorsement letter (recommendation, # of session attended, progress)
  • Home program
  • Medical, test results
  • Report Card
• PASP Standards on Referral

  • nature and cost
  • availability ASAP within one month
  • Required reports for initial evaluations
  • need to refer
  • consent
• discharge: cessation of therapy as discussed by the common understanding of the team
• discharge planning: activities that help a patient transition back to their home, or another setting
• discharge decision: use of therapist's professional reasoning, knowledge, and expertise for formulating discharge recommendations
• discharge recommendation: suggested course of action to ensure smooth transition with a patient's release from a hospital
• SPs role on discharge

  • review and analyze past services
  • identify best program that would result to best outcome
  • implement with ongoing monitoring
• after discharge, follow-up to check the progress (generalized or nawala)
• importance of follow-up

  • environment changes
  • mood changes due to maturation of the patient
  • availability of treatment options