REFERRAL, DISCHARGE & CONTINUITY OF CARE TOOLKIT

Support smoother transitions, stronger coordination, and more complete clinical documentation from referral through case closure.

The CPDL Referral, Discharge & Continuity of Care Toolkit (PR-006) provides behavioral health professionals with an organized collection of editable documentation resources for referrals, transitions of care, discharge, termination, aftercare, re-entry, and case closure.

With 20 editable clinical templates, PR-006 helps clinicians document critical points where care begins, transfers between providers or settings, changes in intensity, or comes to an end—supporting continuity while creating a clearer record of clinical decisions, communication, follow-up, and disposition.

What's Included

The toolkit includes 20 professionally structured clinical templates supporting key transition and continuity-of-care activities, including:

• Referral initiation and outcomes
• Client outreach and engagement
• Hospital admission and discharge coordination
• Transition-of-care summaries
• Continuity-of-care checklists
• External-provider collaboration
• Comprehensive discharge summaries
• Planned termination and transition planning
• Unplanned termination and abandonment-prevention documentation
• Transfer of care and warm handoffs
• Aftercare and continuing-recovery planning
• Case-closure letters
• Lost-to-follow-up documentation
• Client-initiated termination
• Administrative discharge decisions
• Termination-risk and continuity review
• Re-entry or return-to-care requests
• Case-closure quality-assurance review
• Additional referral, discharge, and continuity-of-care documentation

Each primary resource is provided in both editable Microsoft Word format and corresponding reference PDF format, allowing clinicians and organizations to customize materials for their populations, practice settings, workflows, electronic record systems, organizational policies, and continuity-of-care procedures.

Plus 6 Bonus Resources

PR-006 also includes 6 supplemental resources designed to support implementation and strengthen referral, discharge, transition, and continuity-of-care workflows:

• Discharge Transition Workflow Guide
• Discharge Completion Checklist
• Continuity of Care Quick Reference
• Referral Documentation Guide
• Aftercare Planning Checklist
• Post Discharge Follow Up Timeline

These resources provide practical workflow guidance, completion review, continuity-of-care reference support, referral documentation guidance, aftercare planning support, and structured post-discharge follow-up.

Designed for the Transitions That Matter

PR-006 can help clinicians and organizations:

• Create more consistent referral documentation
• Record outreach and engagement efforts
• Strengthen communication across providers and levels of care
• Document hospital and community-care transitions
• Support coordinated transfers and warm handoffs
• Create more comprehensive discharge records
• Distinguish planned, unplanned, administrative, and client-initiated termination
• Document aftercare and continuing-care recommendations
• Track lost-to-follow-up efforts
• Support appropriate re-entry or return to services
• Strengthen case-closure review and documentation quality
• Reduce gaps in the clinical record during transitions of care

Who It's For

Designed for clinical social workers, counselors, therapists, psychologists, clinical supervisors, case managers, care coordinators, behavioral health practices, clinical programs, and other qualified professionals responsible for referrals, discharge planning, transitions, termination, case closure, or continuity of care.

PR-006 is particularly useful for clinicians and organizations seeking a more organized approach to documenting movement into, between, and out of services while supporting communication, continuity, and a clearer record of transition-related clinical decisions.

File Formats

Digital download includes:

• 20 editable Word templates
• 20 corresponding reference PDFs
• 6 bonus resources
• Supporting product and implementation materials

Important Use Notice

These resources are professional documentation aids and do not replace independent clinical judgment, individualized discharge or transition planning, professional supervision or consultation, organizational policy, payer requirements, legal advice, emergency procedures, or applicable federal, state, and local laws and regulations.

Users are responsible for reviewing and adapting the materials to their professional scope, practice setting, client population, organizational policies, payer and recordkeeping requirements, continuity-of-care procedures, privacy and security obligations, and jurisdiction.

Use of these materials does not independently establish legal, regulatory, payer, licensing, accreditation, reimbursement, continuity-of-care, recordkeeping, or HIPAA compliance.

Digital product. No physical item will be shipped.