Continuity of Care & Re-entry Services Sample Clauses

Continuity of Care & Re-entry Services. In collaboration with the behavioral health staff, the Pharmacy Contractor and the DDOC, Provider shall actively participate in comprehensive re-entry coordination aimed at successfully re-assimilating Inmates into the community. The purpose of this program is to ensure continuity of healthcare and access to social services for released Inmates. Provider shall have designated staff at each facility that have, as part of their responsibilities, the oversight of the medical aspects of re- entry and participation in the re-entry and discharge planning teams at each facility. Continuity of care begins at admission and occurs at all transitions of care, including but not limited to intra-system transfers, transfer from and to community-based healthcare facilities, transfers to and from correctional facilities in other jurisdictions, discharges from custody, and re-admission to the DDOC. Provider shall, in accordance with DDOC Policies E-09 Continuity, Coordination, and Quality of Care During Incarceration, 11-E-10 Discharge Planning and DDOC Reentry Planning Policy, ensure that a robust system is in place to ensure continuity of care within and between DDOC facilities and between DDOC facilities and external healthcare facilities and providers. Provider shall provide both statewide and facility-level positions that have, as part of their responsibilities, reentry care coordination and the oversight of continuity of care practices upon admission, transfer, and discharge from DDOC. Provider shall: a. Monitor care coordination activities at the facilities. b. Collaborate with DDOC staff, behavioral health staff, and Pharmacy Contractor on care coordination activities. c. Collect and analyze data on care coordination activities for the purposes of CQI.

Continuity of Care & Re-entry Services. In collaboration with the Behavioral Healthcare Contractor, the Pharmacy Contractor, and BHSAMH, the Provider shall actively participate in comprehensive re-entry coordination aimed at successfully re-assimilating patients into the community. The purpose of this is to ensure continuity of healthcare and access to social services for released patients. The Provider shall have designated staff at each facility that have as part of their responsibilities, the oversight of the medical aspects of re-entry and participation in the re- entry and discharge planning teams at each facility. These designated staff should work flexible schedules to allow for appropriate reentry and discharge services that occur outside of regular business hours. See BHSAMH Policy E-10 Discharge Planning and DDOC Policy 3.12 Reentry Planning Policy, Case Logic Model and Collaborative Case Management Model for more information on these services. Discharge planning begins on admission and occurs at all transitions of care, including but not limited to intra-system transfers, transfer to and from community-based healthcare facilities, transfers to and from correctional facilities in other jurisdictions, discharges from custody, and re-admission to DDOC. In accordance with BHSAMH Policies E-09 Continuity, Coordination, and Quality of Care During Incarceration and E-10 Discharge Planning, and the DDOC Reentry Planning Policy, the Provider shall ensure that a robust system is in place to ensure continuity of care within and between DDOC facilities and between DDOC facilities and external healthcare facilities and providers. The Provider shall provide both statewide and facility level positions that have as part of their responsibility’s reentry care coordination and the oversight of continuity of care practices upon admission, transfer, and discharge from DDOC. The Provider shall provide discharge nurses to assist with medical aspects of discharge and reentry in collaboration with the reentry and behavioral healthcare staff from the behavioral healthcare contract. 1. These staff shall have as part of their core/primary responsibilities - discharge planning and reentry efforts. 2. In collaboration with behavioral healthcare staff and reentry staff, the discharge nurse is the lead coordinator of the discharge process. 3. There shall be a minimum of one discharge nurse at each Level-V facility and one discharge nurse for the Level-IV facilities in New Castle County and one for Sussex County Lev...