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Documentation Index

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Last Updated: 2026-02-25
Module: Clinical (CL)
Spec: CL-29

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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.
Permission KeyDescriptionRecommended Roles
cl.aftercare-plans.viewView aftercare plansAll clinical staff
cl.aftercare-plans.createCreate aftercare plansLicensed clinicians, supervisors
cl.aftercare-plans.updateEdit aftercare plansLicensed clinicians, supervisors
cl.follow-up-contacts.viewView follow-up contactsAll clinical staff
cl.follow-up-contacts.createRecord follow-up contactsClinical staff, care coordinators
cl.readmission-risk.viewView risk assessmentsAll clinical staff
cl.readmission-risk.createCreate risk assessmentsLicensed clinicians, supervisors
cl.warm-handoffs.viewView warm handoffsAll clinical staff
cl.warm-handoffs.createDocument warm handoffsLicensed clinicians, care coordinators

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Role Mapping

RoleRecommended Permissions
Licensed ClinicianAll 9 permissions
Provisionally LicensedAll view + create (plans require co-sign per HR-19)
Care CoordinatorAll view + follow-up create + handoff create
NurseAll view permissions
Peer Supportcl.aftercare-plans.view, cl.follow-up-contacts.view

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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

TablePurposeSoft Delete
cl_aftercare_plansDischarge planning documentsYes (deleted_at)
cl_follow_up_contactsPost-discharge outreach recordsYes
cl_readmission_risk_scoresRisk assessment scoresYes
cl_warm_handoffsProvider handoff documentationYes

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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

IntegrationDescription
CL-18 SDOHSDOH screening data surfaces in the Discharge tab; aftercare plans can auto-populate community resources from SDOH referrals
CL-12 Care TransitionsWarm handoffs reference care transitions (when available)
HR EmployeesWarm handoff caller/receiver fields use the platform Employee Selector
PF PermissionsAll UI elements are gated by permission keys

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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