Discharge & Aftercare Planning — Admin Guide

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Overview

This guide covers administrative configuration for the Discharge & Aftercare Planning feature, including permission setup, compliance alignment, and data governance.

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Permission Configuration

CL-29 uses 9 permission keys. Assign these via Settings > Permissions based on clinical role.

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Role Mapping

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Compliance Standards

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HEDIS FUH (Follow-Up After Hospitalization)

The follow-up contacts feature supports HEDIS FUH measure tracking:

• 7-Day Follow-Up: Mental health follow-up within 7 days of discharge
• 30-Day Follow-Up: Mental health follow-up within 30 days of discharge

Contact types map directly to HEDIS reporting periods. Outcomes track whether patients were reached and their clinical status.

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Joint Commission (CAMBHC)

Aftercare plans align with Joint Commission standards for discharge planning:

• Documented housing arrangements
• Medication continuation plans
• Recovery goals in patient’s own words
• Community resource linkage
• Family/caregiver involvement

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AHCCCS Requirements

Arizona Medicaid (AHCCCS) requires:

• Discharge planning initiated at admission
• Aftercare plans with measurable goals
• Follow-up contact documentation
• Warm handoff documentation for care transitions

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Data Model

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Tables

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Custom Fields

The custom_fields JSONB column on cl_aftercare_plans stores:

• step_down_plan — Level of care step-down pathway
• family_contact_name — Primary family/caregiver name
• family_contact_phone — Family/caregiver phone
• family_involvement_notes — Family involvement in aftercare

Organizations can extend custom_fields via the Custom Fields platform feature (PF-16).

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Data Retention

All discharge-related records follow the organization’s standard clinical data retention policy. Records use soft delete (deleted_at timestamp) — data is hidden from queries but preserved in the database. Only org_admin role can perform hard deletes via RLS policy.

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Row-Level Security

All four tables enforce multi-tenant isolation:

• SELECT: Users can only view records within their organization
• INSERT: organization_id is enforced on all inserts
• UPDATE: Scoped to organization; WITH CHECK prevents cross-tenant data movement
• DELETE: Restricted to org_admin role

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Audit Considerations

• All tables include created_by, updated_by, created_at, updated_at columns
• The update_updated_at_column() trigger automatically maintains updated_at
• Aftercare plan finalization publishes the Discharge.AftercarePlan.Finalized domain event
• Warm handoff documentation creates an auditable record of care transfer responsibility

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Integration Points

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Monitoring

Track these metrics for quality assurance:

• Aftercare plan completion rate — % of discharged patients with aftercare plans
• 7-day follow-up rate — HEDIS FUH compliance metric
• 30-day follow-up rate — HEDIS FUH compliance metric
• Average readmission risk score — Population health indicator
• Warm handoff documentation rate — Care transition quality metric