Managing Transitions to the Community

In Reply: We welcome this opportunity to respond to the letter from Ms. Ralph and Dr. Terrell about our article on the AACP guidelines for transition management and to Dr. Segal's critical commentary on the guidelines (1) that was published in same issue as our article.

What Dr. Segal takes issue with is difficult to discern. He appears to be concerned that current realities present difficult challenges that the guidelines do not recognize. On the contrary, the guidelines were developed to address these barriers to effective transition planning and to provide a vision and some standards for a more rational system of care. We agree that transition plans "most often reflect bureaucratic and financial considerations" and that "services are rarely integrated." The guidelines acknowledge these realities. We believe that the guidelines present an agenda for quality improvement rather than acceptance of the status quo.

Dr. Segal's other criticism seems to be that the guidelines advocate that all service users make transitions through all elements of the continuum of care. Although the guidelines do advocate for the availability of a complete array of services to meet the diverse needs of the service-using population, they in no way imply that these services should be prescribed without regard to individual needs. On the contrary, they emphasize the need to assess and meet individual needs and to include service users in making these determinations.

Dr. Segal also asserts that "transition" is ill defined and euphemistic. Although the term would be euphemistic if used to describe present practices, it is clearly a more appropriate term for describing the processes that the guidelines advocate. The entire AACP document is devoted to describing the meaning of transition in behavioral health services, and thus it is difficult to see how the term should be further elaborated.

In their letter above, Ms. Ralph and Dr. Terrell ask "Where is the community?" We would answer simply that the community is everywhere in this document, and that if there is some aspect of it that has not been considered, we would welcome specific suggestions.

Ms. Ralph and Dr. Terrell state that they feel that the guidelines disregard and denigrate the contributions of collaborating professionals. We were distressed and perplexed by these perceptions. The AACP has nothing but the highest regard for its professional partners in behavioral health care and the important contributions that they make. The AACP intended this document to be a generic, "nondenominational" set of principles to improve deficiencies in transition planning for all professions and professionals dedicated to this important task.

Ms. Ralph and Dr. Terrell also state that social work education is mischaracterized as taking place primarily in the field. We would not presume to characterize social work in this, or any other, way. The passage that they refer to is limited to the relative emphasis on transition planning in training programs and is based on numerous conversations with front-line social workers and their recollections of their training experiences. We would not pretend that this is a scientific sample, and we included it only to illustrate that all professional training programs can improve in this regard.

The authors of the letter also feel that consumers are given an ambivalent message. We think the document clearly and frequently states the value of consumer-driven transition planning. We do note that when people are incapacitated they may not be able to manage complex and multifaceted care unilaterally, and professional support is critical when this is the case. We do not think that these concepts are in conflict with one another or with the authors' perception of how clients should be supported in a managed care environment.