> ## 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 — User Guide

> The Discharge & Aftercare Planning feature helps clinical staff prepare patients for successful transitions from active treatment to community-based recovery.…

## 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**.

***

## Navigating to the Discharge Tab

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.

***

## 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**.

### 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.

***

## 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).

***

## 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.

***

## Interpreting Risk Scores

| Score Range | Level    | Badge Color | Recommended Action                                          |
| ----------- | -------- | ----------- | ----------------------------------------------------------- |
| 0–39        | Low      | Green       | Standard aftercare plan                                     |
| 40–69       | Moderate | Yellow      | Enhanced follow-up, additional resources                    |
| 70–100      | High     | Red         | Intensive aftercare, frequent follow-up, consider step-down |

***

## Troubleshooting

| Issue                                   | Resolution                                                                           |
| --------------------------------------- | ------------------------------------------------------------------------------------ |
| "New Plan" button not visible           | You may lack the `cl.aftercare-plans.create` permission. Contact your administrator. |
| Follow-Up Contacts card not showing     | Requires `cl.follow-up-contacts.view` permission.                                    |
| Employee dropdown empty in warm handoff | Ensure employees are configured in the HR module with active employment status.      |
| SDOH badges not appearing               | Patient must have at least one SDOH screening (CL-18) on file.                       |
| "Link from SDOH" button missing         | No SDOH screening or social referral data exists for this patient.                   |