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Documentation Index

Fetch the complete documentation index at: https://docs.encoreos.io/llms.txt

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

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Overview

The Discharge & Aftercare Planning feature helps clinical staff prepare patients for successful transitions from active treatment to community-based recovery. It provides tools for creating comprehensive aftercare plans, tracking post-discharge follow-up contacts, assessing readmission risk, and documenting provider-to-provider warm handoffs. Access the Discharge tab from any patient chart: Clinical > Patient Chart > Discharge.
  1. Go to Clinical from the main navigation.
  2. Open a patient chart.
  3. Select the Discharge tab.
The Discharge section displays four cards:
  • Aftercare Plans — Comprehensive discharge planning documents
  • Follow-Up Contacts — Post-discharge outreach tracking (HEDIS FUH)
  • Readmission Risk — Risk assessment scores (0–100 scale)
  • Warm Handoffs — Provider-to-provider handoff documentation
If the patient has SDOH screening data (CL-18), summary badges appear at the top showing identified social needs and active referrals.

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Creating an Aftercare Plan

  1. Click New Plan in the Aftercare Plans card.
  2. Fill in the required Plan Date.
  3. Complete any relevant sections:
    • Housing Plan — Post-discharge living arrangements
    • Medication Continuation — Ongoing medication regimen
    • Recovery Goals — Patient’s personal recovery objectives
    • Employment Plan — Vocational or employment support
    • Follow-Up Appointments — Scheduled post-discharge visits
    • Community Resources — Local support services and referrals
  4. Optional sections (expand by clicking):
    • Step-Down Plan — Level of care pathway (e.g., Residential → IOP → OP)
    • Family/Caregiver Involvement — Contact name, phone, and involvement notes
  5. Click Create Plan.

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Linking SDOH Data

If the patient has SDOH screening results (CL-18), a Link from SDOH button appears next to the Community Resources field. Clicking it auto-populates the field with identified social needs and active referrals.

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Recording Follow-Up Contacts

Follow-up contacts track post-discharge outreach per HEDIS Follow-Up After Hospitalization (FUH) standards.
  1. Click Record Follow-Up in the Follow-Up Contacts card.
  2. Select the Contact Type:
    • 7-Day Follow-Up — Required within 7 days of discharge
    • 30-Day Follow-Up — Required within 30 days of discharge
    • Other — Additional follow-up contacts
  3. Enter the Contact Date.
  4. Select the Outcome:
    • Reached — Stable
    • Reached — Needs Support
    • Reached — In Crisis
    • Unable to Reach
    • Declined
  5. Add any Notes about the contact.
  6. Click Record Contact.

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Assessing Readmission Risk

Risk assessments help identify patients who may need enhanced aftercare support.
  1. Click Assess Risk in the Readmission Risk card.
  2. Enter the Assessment Date.
  3. Set the Risk Score (0–100):
    • 0–39 (Low) — Standard aftercare
    • 40–69 (Moderate) — Enhanced follow-up recommended
    • 70–100 (High) — Intensive aftercare planning required
  4. Document Risk Factors contributing to the score.
  5. Add any Notes.
  6. Click Record Assessment.
Risk scores display with color-coded badges: green (low), yellow (moderate), red (high).

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Documenting Warm Handoffs

Warm handoffs document the direct provider-to-provider transfer of care responsibility.
  1. Click Document Handoff in the Warm Handoffs card.
  2. Optionally enter a Care Transition Reference (links to a specific care transition if applicable).
  3. Select the Calling Provider from the employee dropdown.
  4. Select the Receiving Provider from the employee dropdown.
  5. Add Acceptance Notes documenting what was communicated.
  6. Click Document Handoff.
The handoffs table displays the caller and receiver names, acceptance status, and notes.

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Interpreting Risk Scores

Score RangeLevelBadge ColorRecommended Action
0–39LowGreenStandard aftercare plan
40–69ModerateYellowEnhanced follow-up, additional resources
70–100HighRedIntensive aftercare, frequent follow-up, consider step-down

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Troubleshooting

IssueResolution
”New Plan” button not visibleYou may lack the cl.aftercare-plans.create permission. Contact your administrator.
Follow-Up Contacts card not showingRequires cl.follow-up-contacts.view permission.
Employee dropdown empty in warm handoffEnsure employees are configured in the HR module with active employment status.
SDOH badges not appearingPatient must have at least one SDOH screening (CL-18) on file.
”Link from SDOH” button missingNo SDOH screening or social referral data exists for this patient.