Sec. 10.21.05.03. Content and Nature of Aftercare Plans

A. Staff designated by the CEO to assist individuals in aftercare planning shall, as soon as possible after acceptance, in collaboration with the individual:

(1) Initiate the aftercare planning process;

(2) With proper consent, involve in the aftercare planning process:

(a) Community-based service providers;

(b) Family members;

(c) Others who have a personal interest in the individual; and

(d) Third-party payors, including Medical Assistance, the Administration's ASO, or private insurance carriers, if involved, for authorization of outpatient services;

(3) Assist in applying for benefits to which the individual may be entitled and document the outcome of the benefits application process in the individual's record.

B. Before discharge or release, designated staff shall:

(1) Provide notification of the discharge or release:

(a) With proper consent, to:

(i) The individual's next-of-kin;

(ii) As appropriate, the core service agency (CSA);

(iii) Community-based treatment and support services providers rendering services before the individual's inpatient admission; and

(iv) Third-party payors, including Medical Assistance, the Administration's ASO, or private insurance carriers, if involved, for authorization of outpatient services; and

(b) If the individual is a minor, to the parent or guardian; and

(2) Assist the individual to participate in the aftercare plan by:

(a) Explaining to the individual the benefits of:

(i) The aftercare plan;

(ii) Community-based treatment and support services; and

(iii) The involvement of family or others who have a personal interest in the individual;

(b) Encouraging the individual to consent to the aftercare plan; and

(c) Arranging appointments for the individual with appropriate community programs.

C. In collaboration with community programs and government agencies that have agreed to provide aftercare services to the individual after discharge or release, designated staff shall prepare a written aftercare plan that includes:

(1) The individual's:

(a) Name;

(b) Date of birth; and

(c) Address and telephone number upon discharge or release;

(2) For a minor or an individual under guardianship, the name, address, and telephone number of the custodial adult or guardian;

(3) If the individual will reside in program-arranged housing, the name, address, telephone number, and contact person of the placement agency;

(4) The date and type of admission and discharge or release;

(5) The scheduled court date, if any;

(6) The diagnoses, including existing psychiatric, somatic, and dental diagnoses, and level of functional assessment;

(7) The type of treatment initiated;

(8) The name, address, and telephone number of the primary care provider;

(9) Medication information, including the:

(a) Medication prescribed;

(b) Dosage schedules;

(c) Amount of each medication given to the individual upon discharge or release; and

(d) Information necessary to help the individual to obtain the prescribed medication in the community;

(10) The most recent laboratory results, including therapeutic drug levels;

(11) If applicable, a description of:

(a) Allergies, including medication allergies;

(b) Nutritional requirements; and

(c) Active somatic problems requiring continued attention;

(12) Information on the individual's medical insurance coverage, including the:

(a) Company;

(b) Policy number;

(c) Name of the policy holder; and

(d) Preauthorization information, if given, for services to be initiated upon discharge or release;

(13) Entitlements, if any, and status;

(14) The plan for continuing treatment, including but not limited to:

(a) Outpatient mental health treatment services;

(b) Somatic care;

(c) Psychiatric rehabilitation and support services;

(d) When appropriate, substance abuse services; and

(e) Case management;

(15) A list of additional referrals indicated, such as:

(a) Public social services;

(b) Legal aid;

(c) Educational services;

(d) Housing services;

(e) Vocational services;

(f) Peer support services; and

(g) Available crisis services; and

(16) Any identifying information required by the Administration's ASO.