REFUGE HOUSE, INC.

PURPOSE

Refuge House, Inc. recognizes that successful transitions from foster care require continued support and guidance beyond the initial placement period. This policy establishes the agency's commitment to providing comprehensive aftercare services that maintain therapeutic gains, prevent placement disruptions, and support youth in achieving permanency goals. The agency shall provide aftercare services in accordance with T3C Blueprint requirements, with enhanced mandatory services for children receiving Mental & Behavioral Health and IDD/Autism Support Services packages.

POLICY

It is the policy of Refuge House, Inc. to:

1. Provide Comprehensive Aftercare Planning: Begin aftercare planning at admission for all youth, with intensified planning 30 days before projected discharge, ensuring seamless transitions and continuity of care.

2. Deliver Mandatory Aftercare Services: Provide mandatory 6-month aftercare services for all children receiving Mental & Behavioral Health Support Services and IDD/Autism Spectrum Disorder Support Services, with twice-monthly minimum contact requirements.

3. Maintain Qualified Staffing: Ensure aftercare services are delivered by qualified professionals maintaining a 1:25 ratio for specialized packages, with 24/7 crisis response capability.

4. Support Placement Stability: Provide crisis intervention, resource coordination, and intensive support during the critical transition period to prevent re-entry into care.

5. Ensure Service Continuity: Coordinate with community providers, educational systems, and medical professionals to maintain therapeutic gains and developmental progress achieved during placement.

6. Monitor and Report Outcomes: Track aftercare service delivery, youth progress, and placement stability, providing required reports to SSCC/DFPS and utilizing data for continuous improvement.

7. Standardize Aftercare Plan Contents: Every aftercare plan, regardless of Service Package, shall include — at a minimum — the name and contact information for the youth's STAR Health Service Coordinator (if assigned), the name and contact information for the Refuge House Aftercare Case Manager assigned to the youth, documented referrals for continued services, the youth's Education Portfolio, and initial appointments set for continued therapy, medical, MAT (where applicable), or other clinically indicated services where the discharge involves a transition. The case-specific values are populated in the youth's working aftercare plan and maintained in the case record; the operational detail is specified in FC-AF-01.1 Aftercare Services Procedure §2.0.

8. Accommodate Additional Meetings, Staffings, and Referrals: The aftercare plan shall explicitly accommodate, and the aftercare team shall arrange, additional meetings, staffings, or referrals as clinically indicated or as the youth's needs evolve, including case staffings, treatment team meetings, IEP meetings, court-related staffings, and ad-hoc referrals to address emerging needs.

9. Maintain Documentation and Transmit Monthly to SSCC/DFPS: Document every aftercare contact AND every attempted contact, every referral (with status), every case management support activity, and every crisis intervention in the youth's case record. Compile and transmit a monthly aftercare report to the SSCC or DFPS caseworker no later than 3 business days after the end of each reporting month. Operational detail is specified in FC-AF-01.1 Aftercare Services Procedure §3.2 and §5.2.

10. Designate an Aftercare Coordinator (Role-Based) and Provide Cross-Site Aftercare Oversight via the Aftercare Tracking Dashboard: Per the Aftercare Coordinator Job Description, designate an Aftercare Coordinator as a role-based responsibility (~10 hours/week) to provide centralized planning, tracking, compliance, and reporting oversight for aftercare services across both sites. At Refuge House, the Aftercare Coordinator responsibility is held by the Regional Youth Stability Coordinator (RYSC) — a cross-site role into which Heather Sartin transitions at Q1 of the Active Interim Credential period. As part of the Active Interim Credential operational build, establish and maintain an automated Aftercare Tracking Dashboard that aggregates per-youth aftercare contacts, attempted contacts, referrals, and case management support across both sites. The Dashboard is maintained by the Aftercare Coordinator (RYSC), fed by outbound-transitioning Case Managers acting as Aftercare Case Managers, and used to drive monthly SSCC/DFPS reporting and exception-based oversight. The Dashboard supplements — it does not replace — the youth case record as the documentation source of truth. Operational detail, milestones, and the underlying role description are specified in FC-AF-01.1 Aftercare Services Procedure §2.0.1 and §3.5 and in the Aftercare Coordinator Job Description.

PACKAGE-SPECIFIC REQUIREMENTS

CORE REQUIREMENTS - T3C Basic Foster Family Home

Aftercare services for youth in Basic Foster Care shall include:

1. Voluntary Aftercare Planning: Assessment of aftercare needs based on length of stay, clinical indicators, and permanency goals, with services provided when clinically appropriate.

2. Standard Contact Requirements: Monthly minimum contact for voluntary aftercare recipients, with flexibility in contact methods based on youth preference and needs.

3. Resource Coordination: Connection to community resources, educational support, housing assistance, and life skills development as needed.

4. Crisis Support: Access to crisis intervention services during business hours with referral to community crisis resources after hours.

5. Documentation and Reporting: Monthly progress notes and quarterly outcome reports to track service effectiveness and youth stability.

☒ MENTAL & BEHAVIORAL HEALTH SUPPORT SERVICES

For children receiving Mental & Behavioral Health Support Services, aftercare requirements include:

1. Mandatory 6-Month Aftercare: All youth discharging from this package MUST receive 6 months of aftercare services regardless of discharge type or destination.

2. Enhanced Contact Requirements: Twice-monthly minimum contact is required, with in-person contact preferred during the first month post-discharge to ensure therapeutic continuity.

3. Clinical Support Continuation: Licensed therapist consultation available throughout aftercare period to support therapeutic gains and prevent regression.

4. Crisis Response Capability: 24/7 crisis response availability with specialized mental health crisis intervention protocols and immediate mobilization capability.

5. STAR Health Coordination: Continued coordination with STAR Health for psychiatric services, medication management, and behavioral health resource access.

6. 90-Day Continued Stay Reviews: Program Director and Treatment Director must provide written confirmation at each 90-day review that the child continues to require specialized services, with documentation to SSCC/DFPS within 15 business days.

☒ INTELLECTUAL OR DEVELOPMENTAL DISABILITY (IDD)/AUTISM SPECTRUM DISORDER

For children receiving IDD/Autism Support Services, aftercare requirements include:

1. Mandatory 6-Month Aftercare: All youth discharging from this package MUST receive 6 months of aftercare services with specialized developmental support focus.

2. Enhanced Contact Requirements: Twice-monthly minimum contact with communication methods adapted to youth's developmental and communication needs.

3. Medical Support Continuation: RN consultant availability throughout aftercare for medical protocol support, equipment troubleshooting, and health monitoring.

4. Behavioral Support Maintenance: Continued support for behavior plan implementation, sensory accommodations, and environmental modifications in new placement.

5. Skills Transfer Support: Intensive focus on maintaining daily living skills, communication strategies, and routine consistency in receiving placement.

6. 90-Day Continued Stay Reviews: Similar to Mental Health requirements, with written confirmation from both Directors required within 15 business days of review.

☒ T3C TREATMENT FOSTER FAMILY CARE

For youth stepping down from Treatment Foster Care, aftercare includes:

1. Intensive Initial Support: Weekly contact during first month post-discharge, then twice-monthly for remainder of 6-month period.

2. Step-Down Monitoring: Close monitoring of adjustment to less intensive placement with rapid response to emerging needs.

3. Treatment Gains Maintenance: Transfer of all effective behavioral interventions and de-escalation strategies to receiving placement.

4. Placement Preservation Focus: Proactive support to prevent disruption during critical transition from intensive treatment setting.

5. Family Engagement Continuation: Maintain family engagement activities developed during placement as part of the aftercare plan, supporting ongoing connections between the child/youth/young adult and their biological family, relatives, and other identified supportive persons post-discharge. Document family engagement efforts in aftercare service records per FC7-01 Family Connections and Engagement Policy.

☒ SUBSTANCE USE SUPPORT SERVICES

For children receiving Substance Use Support Services, aftercare requirements follow the Mental & Behavioral Health pattern with recovery-specific enhancements:

1. Mandatory 6-Month Aftercare: All youth discharging from this package MUST receive 6 months of aftercare services regardless of discharge type or destination, with specialized focus on recovery support continuity.

2. Enhanced Contact Requirements: Twice-monthly minimum contact is required, with in-person contact preferred during the first month post-discharge to monitor recovery stability and support treatment engagement.

3. Recovery Support Continuation: Connection to community recovery resources, 12-step or alternative recovery programs, and peer support networks as appropriate for the youth's recovery plan.

4. Substance Use Treatment Coordination: Continued coordination with substance use treatment providers to ensure uninterrupted access to individual therapy, group therapy, and medication-assisted treatment (MAT) if applicable.

5. Recovery Stability Monitoring: Ongoing assessment of recovery stability indicators including treatment engagement, support network involvement, and absence of substance use relapse.

6. Relapse Crisis Response: 24/7 crisis response availability with specialized protocols for relapse situations, including immediate assessment, treatment adjustment coordination, and placement preservation support.

7. Recovery Environment Support: Assistance to receiving placement in maintaining substance-free environment and understanding recovery-supportive approaches, including education on non-punitive responses to relapse.

8. STAR Health Coordination: Continued coordination with STAR Health for substance use treatment services, mental health services, and medication management as clinically indicated.

9. 90-Day Continued Stay Reviews (during placement): Program Director and Treatment Director must provide written confirmation at each 90-day review that the child continues to require specialized services, with documentation to SSCC/DFPS within 15 business days per FC-CSR-01.1 Continued Stay Review Procedure.

10. Family Engagement Continuation: Maintain family engagement activities developed during placement as part of the mandatory 6-month aftercare plan, supporting ongoing connections between the youth and their biological family, relatives, and other identified supportive persons post-discharge. Document family engagement efforts in aftercare service records per FC7-01 Family Connections and Engagement Policy.

DEFINITIONS

Aftercare Case Manager - A qualified professional meeting TAC §749 requirements who coordinates and delivers aftercare services while maintaining required caseload ratios under the agency's T3C caseload point system (see the T3C Caseload Point System & Staffing Ratios reference).

Aftercare Services - Supportive services provided following discharge from foster care placement, including case management, crisis intervention, resource coordination, and transition support.

Continued Stay Review - The 90-day review process required for specialized packages to confirm ongoing need for intensive services.

Mandatory Aftercare - Required 6-month aftercare services for Mental & Behavioral Health and IDD/Autism packages per T3C Blueprint requirements.

STAR Health - The comprehensive healthcare program for children in foster care providing medical, dental, vision, behavioral health, and pharmacy services.

Treatment Director - A masters-level mental health professional responsible for clinical oversight of specialized service packages.

Relapse Crisis Response - Specialized 24/7 crisis intervention protocol for youth experiencing or at risk of substance use relapse, including immediate assessment, treatment provider coordination, placement preservation strategies, and non-punitive support approach.

REFERENCES

• T3C Blueprint Standards: Pages 47-55 (Basic Foster Care); Pages 78-93 (Mental & Behavioral Health); Pages 123-135 (IDD/Autism); Pages 71-73 (Treatment Foster Care); Substance Use Support Services (follows Mental & Behavioral Health pattern)
• TAC Chapter 749: Minimum Standards for Child Placing Agencies
• TAC §749.503: Discharge Planning
• TAC §749.1335: Service Plan Reviews
• TAC §749.361: Quality Improvement
• DFPS 24-Hour RCC Requirements (FY26): §§8300–8500 (Transition from Substitute Care, NYTD, Extended Foster Care)

RELATED PROCEDURES

• FC-AF-01.1 Aftercare Services Procedure
• FC-03.1 Individual Service Planning Procedure
• FC-14.1 Discharge and Permanency Planning Procedure
• FC-15.1 Crisis Intervention Procedure
• FC-CSR-01.1 Continued Stay Review Procedure
• FC-SU-01 Substance Use Support Services Policy

FORMS/ATTACHMENTS

• Aftercare Eligibility Assessment
• Aftercare Service Plan Template
• Contact Log Template
• Monthly SSCC/DFPS Report Format
• 90-Day Continued Stay Confirmation Form
• Crisis Response Documentation

This policy document establishes the governing principles for Aftercare Services. The corresponding procedure document (FC-AF-01.1) operationalizes these principles by providing specific implementation details (who, when, where, and how). While policies require Board approval and remain relatively stable, procedures may be updated by the Executive Director to adapt to regulatory changes, technological advancements, or operational improvements without requiring Board approval, provided such changes maintain alignment with the policy's intent.