1. For planned client discharges from Community Care
services, the Case Manager/Coordinator/Support Worker will assist the client
and/or the legal guardian in planning for aftercare services, as
appropriate.� This planning will occur
sufficiently enough in advance of the client leaving the program or ending the
service to ensure that an orderly discharge process takes place.� When not contraindicated all significant
individuals and providers involved in the client's life will be invited to
aftercare planning meetings.
2. A client and/or the legal guardian may refuse
3. Aftercare planning will minimally include filling out
the Community Care Aftercare Services Checklist form.�
4. Also included in the process of aftercare planning,
- Identification of
needs made jointly with client and/or the legal guardian, with a plan to
meet those needs,
- Exploration of
suitable resources with a list of such provided to the client and/or the
- Referrals to
appropriate providers when such action is requested, and
- A plan for
follow-up, if required and if possible, is included.
5. All Aftercare Plans are reviewed by the Case Supervisor.� The signature of the Case Supervisor on the
Aftercare Services Checklist form signifies this review.
6. The Aftercare Services Checklist (and plans when
present) will be filed in the Client�s Case Record and a copy provided to the
client and/or their legal guardian.
Upon ending of
services of any client, the case manager/coordinator will complete a discharge
summary within the appropriate number of days required. (Please see the
Discharge and Termination procedure)