> ## Documentation Index > Fetch the complete documentation index at: https://docs.encoreos.io/llms.txt > Use this file to discover all available pages before exploring further. # Discharge & Aftercare Planning — Integration > Feature ID: CL-29 Status: ✅ Complete — 2026-02-25 Spec Reference: CL-29-discharge-aftercare-planning.md Last Updated: 2026-02-24 **Feature ID:** CL-29\ **Status:** ✅ Complete — 2026-02-25\ **Spec Reference:** [CL-29-discharge-aftercare-planning.md](../../../specs/cl/specs/CL-29-discharge-aftercare-planning.md)\ **Last Updated:** 2026-02-24 *** ## Overview CL-29 formalizes discharge planning and aftercare workflows: discharge assessment at admission, structured aftercare plans, warm handoff documentation, 7-day/30-day follow-up tracking (HEDIS FUH), readmission risk assessment, and family/caregiver and SDOH linkage. Integrations: CL-12 (transitions), CL-03 (treatment plan), CL-07 (safety), CL-10 (HEDIS FUH), CL-18 (SDOH), RH (housing coordination). *** ## Quick Reference * **Purpose:** Discharge planning and aftercare workflows (assessment, aftercare plan, warm handoff, 7/30-day follow-up, readmission risk, RH housing coordination). * **Scope:** Four tables (cl\_aftercare\_plans, cl\_follow\_up\_contacts, cl\_readmission\_risk\_scores, cl\_warm\_handoffs); CL-12 transition\_id link; CL-10 HEDIS FUH; RH event/API. * **Key links:** [Spec](../../../specs/cl/specs/CL-29-discharge-aftercare-planning.md), [CL-12 Care Coordination & Transitions](../../../specs/cl/specs/CL-12-care-coordination-transitions.md), [CROSS\_CORE\_INTEGRATIONS.md](./CROSS_CORE_INTEGRATIONS.md). *** ## Decision Tree 1. **Trigger:** Discharge planned or aftercare plan finalized. 2. **Actor:** Clinician / care coordinator (CL-29); RH for placement; reporting for FUH. 3. **Discharge assessment at admission** → Create/update aftercare plan; link transition\_id (CL-12). 4. **Aftercare plan finalized** → Publish Discharge.AftercarePlan.Finalized (platform layer); RH and reporting subscribe. 5. **RH referral status change** → RH.Referral.Status event (or API); CL-29 may consume for housing\_plan sync. 6. **7-day / 30-day follow-up** → cl\_follow\_up\_contacts; CL-10 HEDIS FUH consumes (query or event TBD). *** ## Pattern Library * **Discharge assessment:** Form/workflow at admission; store in cl\_aftercare\_plans; link to cl\_care\_transitions via transition\_id. * **Warm handoff:** Document caller, receiver, acceptance, time in cl\_warm\_handoffs; PHI; RLS via cl\_has\_org\_access. * **Follow-up tracking:** cl\_follow\_up\_contacts with contact\_type 7\_day | 30\_day; feed HEDIS FUH per CL-10; use platform layer (message broker or REST) for reporting. *** ## Common Mistakes | Mistake | Mitigation | | --------------------------------------- | ----------------------------------------------------------------------------- | | Forgetting FORCE ROW LEVEL SECURITY | Add ALTER TABLE ... FORCE ROW LEVEL SECURITY after ENABLE for all four tables | | Missing cl\_has\_org\_access pre-flight | Verify function exists before running migrations (Phase 0 check) | | Direct CL → RH table access | Use events or platform API only; CL documents, RH owns placement | | Omitting WITH CHECK on UPDATE | Every UPDATE policy must include WITH CHECK (constitution §5.2.4) | | Not seeding permission keys | Migration seeds cl.aftercare-plans.*, cl.follow-up-contacts.*, etc. per PF-30 | *** ## Pre-Flight Checklist * [ ] Phase 0: DB check that cl\_has\_org\_access exists; fail deployment if missing. * [ ] Migration: four tables, indexes, updated\_at triggers (pf\_set\_updated\_at), RLS + FORCE RLS. * [ ] Permission keys seeded; roles assigned. * [ ] Event contracts (below) documented; CROSS\_CORE\_INTEGRATIONS.md updated. * [ ] RLS tests pass; cross-tenant isolation verified. *** ## Integration Points (from Spec) | Dependency | Pattern | Purpose | | ------------------------ | ------------------------- | ----------------------------------------------------------------------------------------------------------- | | CL-12 (Care Transitions) | Internal / Data | Link aftercare plan to transition via `transition_id`; CL-29 extends with structured aftercare | | CL-03 (Treatment Plan) | Internal / Data | Goals at discharge; treatment plan context for aftercare | | CL-07 (Safety Planning) | Internal / Data | Safety planning at discharge | | CL-10 (HEDIS FUH) | Internal / Data | 7-day and 30-day follow-up contacts feed HEDIS FUH | | CL-18 (SDOH) | Internal / Data | SDOH referrals at discharge; community resource linkage | | RH (Recovery Housing) | Cross-core / Event or API | Housing coordination at residential discharge; RH owns placement; CL-29 documents coordination and referral | *** ## API / Data Contracts * **CL-12 transition link:** `cl_aftercare_plans.transition_id` references `cl_care_transitions(id)`; optional when transition record exists. * **CL-10 HEDIS FUH:** Follow-up contact records (`cl_follow_up_contacts` with `contact_type` 7\_day/30\_day) feed HEDIS FUH logic per CL-10; contract TBD (query or event). * **RH housing:** Coordination documented in aftercare plan (`housing_plan`); placement owned by RH; integration contract TBD (event or API for referral status). *** ## Event Contracts * **Planned:** Discharge completed or aftercare plan finalized may publish events for RH or reporting. Explicit contract placeholders: **Discharge.AftercarePlan.Finalized (event)** | Attribute | Value | | ----------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Channel / topic | `platform.events.aftercare` (or equivalent) | | Publisher | CL-29 service when aftercare plan is finalized | | Subscribers | RH (housing coordination), reporting (FUH / analytics) | | Payload (minimal) | `organization_id`, `transition_id` (cl\_aftercare\_plans.transition\_id), `aftercare_plan_id`; optional: `housing_plan` (text), `contact_type` (cl\_follow\_up\_contacts) | | Transport | Platform message broker or REST gateway | | Contract type | Event | **RH.Referral.Status (event or REST)** | Attribute | Value | | ----------------- | -------------------------------------------------------------------------------- | | Channel / topic | `platform.events.referrals` (or REST endpoint TBD) | | Publisher | RH when referral/placement status changes | | Subscribers | CL-29 (optional: update housing\_plan or handoff state) | | Payload (minimal) | `organization_id`, `referral_id`, `status`; reference existing symbols as needed | | Transport | Platform message broker or REST gateway | | Contract type | Event (preferred) or REST API (method/endpoint/request-response TBD) | These contracts are listed in [CROSS\_CORE\_INTEGRATIONS.md](./CROSS_CORE_INTEGRATIONS.md); integration owners: CL team (CL-29), RH team (referral status). *** ## Security and RLS * All CL-29 tables use `organization_id` (and `site_id` on `cl_follow_up_contacts`, `cl_readmission_risk_scores`). RLS via SECURITY DEFINER (e.g. `cl_has_org_access`); UPDATE policies include WITH CHECK (constitution §5.2.4). Plans, assessments, and handoffs are PHI; no RLS policy may query RLS-protected tables directly (§5.7). *** ## Related Docs * [CL-12](../../../specs/cl/specs/CL-12-care-coordination-transitions.md) — Care coordination & transitions * [CROSS\_CORE\_INTEGRATIONS.md](./CROSS_CORE_INTEGRATIONS.md) — Integration matrix (CL ↔ RH)