Specifications include, but are not limited to: A. Cases designated as Medical Discharges: The Medical Discharge Unit receives referrals from RIDOC medical, counseling and discharge planning units and from the RI Parole Board. The referrals include specific information to support the referral. In the case of a medical parole request the referral will follow the RIGL 13-8.1 guidelines for medical parole and the corresponding RIDOC policy 20.08-3. General referrals should be forwarded to the Discharge Planning Unit within 9 months of scheduled release, aiming for no less than 30-60 days prerelease, unless the medical condition meets criteria for services. The Medical Discharge Planner reviews the medical record of the client. This includes survey of Unresolved Diagnoses, active Med Orders, and any relevant referrals and diagnostic studies pertinent to ongoing conditions requiring aftercare. If full case management and specialty care appears to be required, the Medical Discharge Planner meets with the client to obtain releases and contact information about previous specialty care providers or present providers who will continue care or make referrals to appropriate providers in the client’s community. The Medical Discharge Planner schedules post-release specialty care appointments and assesses resources for payment and transportation to those appointments, including family support, Medicaid eligibility, and private insurance. If the level of care requires a placement in a residential medical facility the medical discharge planner works with community providers to find a bed that is appropriate to that level of care. A community Health worker may also assist in planning for an individual’s release and will follow up in the community to ensure clients have access to all treatment needs. The Medical Discharge Planner will update the RIDOC case management database Transition from Prison to Community Data System (TPCDS) with all scheduled appointments, provider contact information (omitting diagnoses from TPCDS), financial arrangements and identified transportation resources. If the client has meds, the Medical Discharge Planner will create a request for 30-day prescription if the release is to a residential facility. If the client is being released to the community, the medical discharge planner will triage the case. In complex cases, the medical discharge planner will create a request for meds; otherwise, will work with the patient who makes the request to the dispensary. B. Cases who require only a specialty referral not a residential placement: If the client is not eligible for medically managed release, the medical discharge planner will update TPCDS Reentry Plan to reflect that the client can appropriately seek follow-up or preventive care from community resources including their established Primary Care Provider (PCP), the local Federally Qualified Health center (FQHC) and the local Community Mental Health Organization (CMHO). If no specialty care is required, but the client is prescribed medications which should be continued in the community, the Medical Discharge Planner schedules follow-up appointments with the recommended community agencies. If a limited amount of specialty care appears to be required but the release is not managed by the medical discharge unit, the Medical Discharge Planner meets with the client to obtain releases and contact information about previous specialty care providers or present providers who will continue care or make referrals to appropriate providers in the client’s community. The Medical Discharge Planner may assist the regional planner with Medicaid and SSDI applications for clients requiring specialty follow-up or make a referral to the appropriate person or agency to do so. The Medical Discharge Planner updates TPCDS with all scheduled appointments, provider contact information (omitting diagnoses from TPCDS) and identified transportation resources.
