"The discharge planning process begins at the time a client is admitted into treatment. Based upon information obtained during the initial assessment and authorization, immediate efforts may need to begin to secure housing, access case management services, obtain entitlements, or to refer the client to a more intensive and specialized program. A promising practice is for multiple providers to co-develop a single, integrated transition/reentry plan for each soon-to-be released inmate. This plan is developed in the last six months of incarceration and finalized 30-90 days prior to release. In this information exchange, corrections would first generate a list of inmates who are within the defined “pre-release” window of time, and then develop a draft transition plan for each inmate. The corrections discharge or reentry case manager would then send a draft transition plan to the specific service providers involved with or proposed for a given client, then receives and incorporates feedback from the other providers. Once the feedback is incorporated, the process is repeated for all service providers to review and approve the finalized transition/reentry plan." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan

Attributes
CaseManager	caseManger
String	clientFutureGoals	"This class captures client future goals." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.clientFutureGoals
	familyOrSignificantOtherInvolvement	"Family/Significant Other who will be providing support to client, with addresses and phone numbers so that discharge follow up can be done by CBH Member Services and the respective case management units, if applicable." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.familyOrSignificantOtherInvolvement
HousingAtDischarge	housing	"This class captures information related to housing such as PDR, CRR, recovery house, location, date of placement, contact person and phone number." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.housing
String	meaningfulDailyActivities	"This class captures meaningful daily activities of the Client." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.meaningfulDailyActivities
String	medicalSupport	"This class captures medical supports including the name of the primary care physician, phone number and appointment date/location if applicable." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.medicalSupport
String	mentalHealthReport	"This class captures information contained on a Behavioral Health Summary Report." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.mentalHealthReport
IndividualProvider	nextLevelOfCareProviderName	"This class captures information related to next level of care provider, date and time of appointment." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.nextLevelOfCareProviderName
String	specializedServices	"This class captures information related to specialized services such as interpreter service, home care, mental health, EPSDT, etc. Specific dates, location and primary contact people should be identified along with phone numbers." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.specializedServices
«EntryPoint» MedicationList	substanceAbuseMedications	"This class captures medications used to treat substance abuse as well as the information related to those medications including dosage and frequency as well as the date/time of next medication appointment with physician and/or psychiatrist. For example, this class would be used to convey the dosage of methadone maintenance protocol when applicable to clients transitioning to Outpatient Methadone Maintenance." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.substanceAbuseMedications

 caseManger

Public CaseManager caseManger

Constraints:

Properties:

Aggregation	None
Alias
Association	dischargeTransitionAfterCarePlan_caseManger
Association End
Class	DischargeTransitionAfterCarePlan
Datatype
Default
Default Value
Is Composite	false
Is Derived	false
Is Derived Union	false
Is Leaf	false
Is Ordered	false
Is Read Only	false
Is Static	false
Is Unique	true
Keywords
Lower	0
Lower Value	(0)
Multiplicity	0..1
Name	caseManger
Name Expression
Namespace	DischargeTransitionAfterCarePlan
Opposite
Owner	DischargeTransitionAfterCarePlan
Owning Association
Owning Template Parameter
Qualified Name	FHIM::BehavioralHealth::DischargeTransitionAfterCarePlan::caseManger
Stereotype
Template Parameter
Type	CaseManager
Upper	1
Upper Value	(1)
Visibility	Public

 clientFutureGoals

Public String clientFutureGoals

"This class captures client future goals." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.clientFutureGoals

Constraints:

Properties:

Aggregation	None
Alias
Association
Association End
Class	DischargeTransitionAfterCarePlan
Datatype
Default
Default Value
Is Composite	false
Is Derived	false
Is Derived Union	false
Is Leaf	false
Is Ordered	false
Is Read Only	false
Is Static	false
Is Unique	true
Keywords
Lower	1
Lower Value	(1)
Multiplicity	1
Name	clientFutureGoals
Name Expression
Namespace	DischargeTransitionAfterCarePlan
Opposite
Owner	DischargeTransitionAfterCarePlan
Owning Association
Owning Template Parameter
Qualified Name	FHIM::BehavioralHealth::DischargeTransitionAfterCarePlan::clientFutureGoals
Stereotype
Template Parameter
Type	String
Upper	1
Upper Value	(1)
Visibility	Public

 familyOrSignificantOtherInvolvement

Public  familyOrSignificantOtherInvolvement

"Family/Significant Other who will be providing support to client, with addresses and phone numbers so that discharge follow up can be done by CBH Member Services and the respective case management units, if applicable." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.familyOrSignificantOtherInvolvement

Constraints:

Properties:

Aggregation	None
Alias
Association
Association End
Class	DischargeTransitionAfterCarePlan
Datatype
Default
Default Value
Is Composite	false
Is Derived	false
Is Derived Union	false
Is Leaf	false
Is Ordered	false
Is Read Only	false
Is Static	false
Is Unique	true
Keywords
Lower	1
Lower Value	(1)
Multiplicity	1
Name	familyOrSignificantOtherInvolvement
Name Expression
Namespace	DischargeTransitionAfterCarePlan
Opposite
Owner	DischargeTransitionAfterCarePlan
Owning Association
Owning Template Parameter
Qualified Name	FHIM::BehavioralHealth::DischargeTransitionAfterCarePlan::familyOrSignificantOtherInvolvement
Stereotype
Template Parameter
Type
Upper	1
Upper Value	(1)
Visibility	Public

 housing

Public HousingAtDischarge housing

"This class captures information related to housing such as PDR, CRR, recovery house, location, date of placement, contact person and phone number." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.housing

Constraints:

Properties:

Aggregation	None
Alias
Association
Association End
Class	DischargeTransitionAfterCarePlan
Datatype
Default
Default Value
Is Composite	false
Is Derived	false
Is Derived Union	false
Is Leaf	false
Is Ordered	false
Is Read Only	false
Is Static	false
Is Unique	true
Keywords
Lower	1
Lower Value	(1)
Multiplicity	1
Name	housing
Name Expression
Namespace	DischargeTransitionAfterCarePlan
Opposite
Owner	DischargeTransitionAfterCarePlan
Owning Association
Owning Template Parameter
Qualified Name	FHIM::BehavioralHealth::DischargeTransitionAfterCarePlan::housing
Stereotype
Template Parameter
Type	HousingAtDischarge
Upper	1
Upper Value	(1)
Visibility	Public

 meaningfulDailyActivities

Public String meaningfulDailyActivities

"This class captures meaningful daily activities of the Client." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.meaningfulDailyActivities

Constraints:

Properties:

Aggregation	None
Alias
Association
Association End
Class	DischargeTransitionAfterCarePlan
Datatype
Default
Default Value
Is Composite	false
Is Derived	false
Is Derived Union	false
Is Leaf	false
Is Ordered	false
Is Read Only	false
Is Static	false
Is Unique	true
Keywords
Lower	1
Lower Value	(1)
Multiplicity	1
Name	meaningfulDailyActivities
Name Expression
Namespace	DischargeTransitionAfterCarePlan
Opposite
Owner	DischargeTransitionAfterCarePlan
Owning Association
Owning Template Parameter
Qualified Name	FHIM::BehavioralHealth::DischargeTransitionAfterCarePlan::meaningfulDailyActivities
Stereotype
Template Parameter
Type	String
Upper	1
Upper Value	(1)
Visibility	Public

 medicalSupport

Public String medicalSupport

"This class captures medical supports including the name of the primary care physician, phone number and appointment date/location if applicable." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.medicalSupport

Constraints:

Properties:

Aggregation	None
Alias
Association
Association End
Class	DischargeTransitionAfterCarePlan
Datatype
Default
Default Value
Is Composite	false
Is Derived	false
Is Derived Union	false
Is Leaf	false
Is Ordered	false
Is Read Only	false
Is Static	false
Is Unique	true
Keywords
Lower	1
Lower Value	(1)
Multiplicity	1
Name	medicalSupport
Name Expression
Namespace	DischargeTransitionAfterCarePlan
Opposite
Owner	DischargeTransitionAfterCarePlan
Owning Association
Owning Template Parameter
Qualified Name	FHIM::BehavioralHealth::DischargeTransitionAfterCarePlan::medicalSupport
Stereotype
Template Parameter
Type	String
Upper	1
Upper Value	(1)
Visibility	Public

 mentalHealthReport

Public String mentalHealthReport

"This class captures information contained on a Behavioral Health Summary Report." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.mentalHealthReport

Constraints:

Properties:

Aggregation	None
Alias
Association
Association End
Class	DischargeTransitionAfterCarePlan
Datatype
Default
Default Value
Is Composite	false
Is Derived	false
Is Derived Union	false
Is Leaf	false
Is Ordered	false
Is Read Only	false
Is Static	false
Is Unique	true
Keywords
Lower	1
Lower Value	(1)
Multiplicity	1
Name	mentalHealthReport
Name Expression
Namespace	DischargeTransitionAfterCarePlan
Opposite
Owner	DischargeTransitionAfterCarePlan
Owning Association
Owning Template Parameter
Qualified Name	FHIM::BehavioralHealth::DischargeTransitionAfterCarePlan::mentalHealthReport
Stereotype
Template Parameter
Type	String
Upper	1
Upper Value	(1)
Visibility	Public

 nextLevelOfCareProviderName

Public IndividualProvider nextLevelOfCareProviderName

"This class captures information related to next level of care provider, date and time of appointment." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.nextLevelOfCareProviderName

Constraints:

Properties:

Aggregation	None
Alias
Association
Association End
Class	DischargeTransitionAfterCarePlan
Datatype
Default
Default Value
Is Composite	false
Is Derived	false
Is Derived Union	false
Is Leaf	false
Is Ordered	false
Is Read Only	false
Is Static	false
Is Unique	true
Keywords
Lower	1
Lower Value	(1)
Multiplicity	1
Name	nextLevelOfCareProviderName
Name Expression
Namespace	DischargeTransitionAfterCarePlan
Opposite
Owner	DischargeTransitionAfterCarePlan
Owning Association
Owning Template Parameter
Qualified Name	FHIM::BehavioralHealth::DischargeTransitionAfterCarePlan::nextLevelOfCareProviderName
Stereotype
Template Parameter
Type	IndividualProvider
Upper	1
Upper Value	(1)
Visibility	Public

 specializedServices

Public String specializedServices

"This class captures information related to specialized services such as interpreter service, home care, mental health, EPSDT, etc. Specific dates, location and primary contact people should be identified along with phone numbers." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.specializedServices

Constraints:

Properties:

Aggregation	None
Alias
Association
Association End
Class	DischargeTransitionAfterCarePlan
Datatype
Default
Default Value
Is Composite	false
Is Derived	false
Is Derived Union	false
Is Leaf	false
Is Ordered	false
Is Read Only	false
Is Static	false
Is Unique	true
Keywords
Lower	1
Lower Value	(1)
Multiplicity	1
Name	specializedServices
Name Expression
Namespace	DischargeTransitionAfterCarePlan
Opposite
Owner	DischargeTransitionAfterCarePlan
Owning Association
Owning Template Parameter
Qualified Name	FHIM::BehavioralHealth::DischargeTransitionAfterCarePlan::specializedServices
Stereotype
Template Parameter
Type	String
Upper	1
Upper Value	(1)
Visibility	Public

 substanceAbuseMedications

Public «EntryPoint» MedicationList substanceAbuseMedications

"This class captures medications used to treat substance abuse as well as the information related to those medications including dosage and frequency as well as the date/time of next medication appointment with physician and/or psychiatrist. For example, this class would be used to convey the dosage of methadone maintenance protocol when applicable to clients transitioning to Outpatient Methadone Maintenance." - HL7 Behavioral Health Record DAM R2, DischargeTransition/AfterCarePlan.substanceAbuseMedications

Constraints:

Properties:

Aggregation	None
Alias
Association
Association End
Class	DischargeTransitionAfterCarePlan
Datatype
Default
Default Value
Is Composite	false
Is Derived	false
Is Derived Union	false
Is Leaf	false
Is Ordered	false
Is Read Only	false
Is Static	false
Is Unique	true
Keywords
Lower	1
Lower Value	(1)
Multiplicity	1
Name	substanceAbuseMedications
Name Expression
Namespace	DischargeTransitionAfterCarePlan
Opposite
Owner	DischargeTransitionAfterCarePlan
Owning Association
Owning Template Parameter
Qualified Name	FHIM::BehavioralHealth::DischargeTransitionAfterCarePlan::substanceAbuseMedications
Stereotype
Template Parameter
Type	«EntryPoint» MedicationList
Upper	1
Upper Value	(1)
Visibility	Public