Procedure

Aftercare Services Procedure

Refuge House, Inc.
Last updated: July 24, 2026 · Source: policies-procedures/Procedure/Aftercare Services Procedure.md

REFUGE HOUSE, INC.

Procedure Information Details
PROCEDURE NAME Aftercare Services Procedure
PROCEDURE NUMBER FC-AF-01.1
RELATED POLICY FC-AF-01 Aftercare Services Policy
EFFECTIVE DATE 5/22/2026
REVISION DATE 12.27.2024.1; 12.09.2025.1; 05.2026.2
LAST UPDATED 5/15/2026
LAST APPROVED 5/22/2026

PURPOSE AND OVERVIEW

This procedure operationalizes the Aftercare Services Policy (FC-AF-01) by providing detailed implementation steps for planning and delivering aftercare services to children, youth, and young adults transitioning from foster care placement. The procedure ensures compliance with T3C Blueprint requirements and maintains continuity of care during critical transition periods, with enhanced requirements for specialized service packages.

The importance of aftercare services cannot be overstated. Research consistently shows that the first six months following discharge from care represent a critical period where youth are most vulnerable to placement disruption, re-entry into care, or negative life outcomes. By providing structured support during this transition, we significantly increase the likelihood of successful permanency and positive youth development.

RELATIONSHIP BETWEEN POLICY AND PROCEDURE

The Aftercare Services Policy establishes the agency's commitment to supporting successful transitions through comprehensive aftercare planning and service delivery. This procedure document provides the specific operational steps, timelines, responsibilities, and documentation requirements necessary to implement that policy commitment effectively across all service packages. While the policy defines what we will do and why, this procedure details who will do it, when, where, and how.

RESPONSIBILITY

PROCEDURE

1. AFTERCARE ELIGIBILITY AND INITIATION

Purpose and Overview

Aftercare services begin with proper identification of eligible youth and timely initiation of planning processes. Early identification ensures smooth transitions and maintains therapeutic gains achieved during placement. This section establishes clear protocols for determining eligibility and initiating services across all packages.

1.1 Eligibility Determination

Who How When Where Regulatory Reference
Case Manager
  1. Review eligibility criteria for each youth: Basic Foster Care: Length of stay 30+ days, clinical indicators, voluntary participation Mental & Behavioral Health: ALL discharges (mandatory) IDD/Autism: ALL discharges (mandatory) Treatment Foster Care: ALL step-downs (mandatory)
  2. Document eligibility determination
  3. Notify Aftercare Coordinator
 At admission and monthly thereafter Radius eligibility module T3C Blueprint p.47-55, p.86, p.134
Program Director
  1. Review and approve eligibility determinations
  2. For Mental Health/IDD: Confirm mandatory status
  3. For Basic/Add-ons: Assess clinical need
  4. Authorize service initiation
 Within 48 hours of determination Approval documentation T3C Blueprint requirements
Aftercare Coordinator
  1. Enter eligible youth into aftercare tracking system
  2. Assign to Aftercare Case Manager based on: - Current caseload (maintain 1:25 ratio) - Geographic location - Specialized expertise needs
  3. Initiate planning timeline
 Within 24 hours of approval Aftercare tracking database T3C Blueprint aftercare requirements

1.2 SSCC/DFPS Notification

Who How When Where Regulatory Reference
Case Manager
  1. Prepare aftercare notification including: - Youth identifying information - Service package designation - Projected discharge date - Aftercare service level - Contact information
  2. Submit to SSCC/DFPS
 Within 5 business days of eligibility approval IMPACT system T3C Blueprint aftercare requirements
Aftercare Coordinator
  1. Track notification compliance
  2. Confirm SSCC receipt
  3. Address any questions
  4. Update tracking log
 Within 24 hours of submission Compliance tracking TAC §749.361

2. AFTERCARE PLANNING PROCESS

Purpose and Overview

Comprehensive aftercare planning ensures all necessary supports are in place before discharge and continue throughout the transition period. The planning process varies by package but always emphasizes continuity, stability, and youth engagement.

2.0 Aftercare Plan — Required Contents (All Packages)

The aftercare plan for every youth — regardless of Service Package — must include the following items. The Policy/Procedure establishes the requirement; the per-case values are populated in the youth's working aftercare plan and maintained in the case record.

Required Plan Contents:

Item Description Source
STAR Health Service Coordinator Name and contact information (phone, email) for the youth's assigned STAR Health Service Coordinator, if assigned. If no Service Coordinator is yet assigned, document the STAR Health Member Services line and the date of the most recent coordination request. FC10-01.2 STAR Health Coordination Procedure
CPA Aftercare Services Case Manager Name and contact information (phone, email, on-call number) for the Refuge House Aftercare Case Manager assigned to the youth. For SA SU/STASS/TFFC youth, this is typically the outbound-transitioning Case Manager who carried the case during placement (see §2.0.1 below). RH staffing model
Referrals for continued services Documented referrals to community-based providers, mental/behavioral health services, substance use treatment, medical/dental care, educational supports, and any package-specific services. Each referral records: provider name, contact information, service requested, referral date, and current status. FC10-01.2; T3C Blueprint
Education Portfolio Compiled educational record for the youth including: current school enrollment and contact, IEP/504 plan documentation (if applicable), educational testing results, transcripts, attendance records, accommodations in place, and educational liaison contact. Maintained by Tamika Peake (Dallas — Education Specialist) and the Regional Youth Stability Coordinator. Education Liaison function (Org Chart Function #5)
Initial appointments set Confirmed scheduled appointments for: continued therapy or psychiatric care, medication management (where applicable), MAT continuation (SU package, if applicable), medical/dental follow-up, RN consultation (IDD/Autism, if applicable), and any other clinically indicated services. Each appointment records: provider, date, time, location, and confirmation status. Required when the discharge involves a transition to a new placement, new providers, or new service authorizations. T3C Blueprint p.86, p.134
Additional meetings/staffings/referrals The aftercare plan must explicitly accommodate — and the aftercare team will arrange — additional meetings, staffings, or referrals as clinically indicated, as the youth's needs evolve, or as requested by the youth, family/caregivers, SSCC/DFPS, or treatment providers. This includes case staffings, treatment team meetings, IEP meetings, court-related staffings, and ad-hoc referrals to address emerging needs. T3C Blueprint

Plan Authorship and Signoff:

The aftercare plan is drafted by the placing Case Manager (during the 30/14/7-day pre-discharge planning windows specified in §2.1–§2.4) and signed by the youth (when age-appropriate), the receiving caregiver, and the Aftercare Coordinator (Regional Youth Stability Coordinator / RYSC — Heather Sartin at Q1 Active Interim). Copies are entered into Radius and the youth's case record; a copy is provided to SSCC/DFPS as part of the discharge packet.

2.0.1 Aftercare Case Manager Staffing Model and Aftercare Coordinator Role

Aftercare Case Managers — direct service delivery via outbound-CM continuity. The CPA Aftercare Services Case Manager function is staffed primarily through outbound-transitioning Case Managers maintaining continuity with the youth they carried during placement. This warm-handoff model preserves the therapeutic relationship through the 6-month aftercare period and is clinically preferable to assigning a previously-uninvolved Aftercare CM. The outbound CM continues to log contacts, attempted contacts, referrals, and case-management support in Radius (and, once live, in the Aftercare Tracking Dashboard — see §3.5). Per the Aftercare Coordinator Job Description, Case Managers conducting aftercare activities receive 0.5 caseload points per active aftercare case unless services are formally declined and documented.

Current outbound-CM coverage by site (per the 8-Function Organizational Chart):

When an outbound CM is unavailable (departure, leave, or reassignment), the Aftercare Coordinator reassigns the case to another credentialed CM and documents the handoff in the case record.

Aftercare Coordinator — centralized planning, tracking, compliance, and reporting via the RYSC role. The Aftercare Coordinator is a role-based responsibility (~10 hours/week) assigned per the Aftercare Coordinator Job Description. At Refuge House, the Aftercare Coordinator responsibility is held by the Regional Youth Stability Coordinator (RYSC) — a cross-site role serving both Dallas and San Antonio. Heather Sartin transitions into the RYSC role (and therefore the Aftercare Coordinator responsibility) at Q1 of the Active Interim Credential period, which is the Dashboard activation milestone (see §3.5.4).

Per the Aftercare Coordinator JD, the role functions as the "central nervous system" for aftercare:

The Aftercare Coordinator (RYSC) reports to the Program Director (Dallas: Kelsey Batista; San Antonio: Lindsay Reed, interim) for supervisory and escalation purposes, and consults the Treatment Director for clinical questions. The full role description is documented in the Aftercare Coordinator Job Description (filed with the Functional Job Description Compilation and provided as a reference document with this submission).

2.1 Basic Foster Care Planning

Who How When Where Regulatory Reference
Case Manager
  1. Complete Aftercare Services Plan form including: - Housing stability assessment - Educational/vocational continuity - Healthcare transition needs - Life skills support requirements - Natural support network mapping - Financial literacy needs
  2. Engage youth in planning using TBRI approaches
  3. Coordinate with receiving placement
 30 days before projected discharge Aftercare Services Plan form (previewforms.refugehouse.org) TAC §749.503
Aftercare Case Manager
  1. Review and enhance plan with: - Community resource mapping - Support service scheduling - Contact schedule (monthly minimum) - Crisis response resources - Transportation planning
  2. Meet with youth to explain services
  3. Have youth/guardian sign acknowledgment
 14 days before discharge Signed Aftercare Services Plan T3C Blueprint p.47-55

2.2 ☒ Mental & Behavioral Health Enhanced Planning

Who How When Where Regulatory Reference
Treatment Director
  1. Convene treatment team for aftercare planning
  2. Develop clinical transition plan including: - Therapeutic service continuity - Psychiatric care transition - Crisis intervention protocols - Medication management plan - STAR Health coordination
  3. Identify community mental health resources
 30 days before discharge Treatment team meeting CRITICAL: T3C Blueprint p.86
Licensed Therapist
  1. Create therapeutic transition summary: - Diagnosis and treatment history - Effective interventions - Crisis triggers and responses - Coping strategies that work - Recommended therapy frequency
  2. Schedule warm handoff with new therapist
 14 days before discharge Clinical documentation T3C Blueprint p.78-93
Aftercare Case Manager
  1. Establish mandatory service schedule: - Twice-monthly contact (minimum) - First month: in-person preferred - 24/7 crisis availability - Family/caregiver check-ins - Service engagement monitoring
  2. Document in aftercare plan
 7 days before discharge Aftercare service plan MANDATORY: T3C Blueprint p.86
Aftercare Case Manager
  1. Maintain family/caregiver engagement post-discharge: - Twice-monthly contact with family/caregivers (minimum) - Consult with caregivers on mental health-informed responses to youth behaviors and crisis triggers - Verify implementation of therapeutic coping strategies in the home environment - Identify caregiver support gaps and arrange targeted coaching or training - Document all family engagement contacts
  2. Connect families to community mental health family support resources and peer family groups
 Ongoing post-discharge; begin coordination 7 days before discharge Family Engagement Log FC7-01 MH Aftercare Family Engagement; T3C Blueprint p.86

2.3 ☒ IDD/Autism Enhanced Planning

Who How When Where Regulatory Reference
RN Consultant
  1. Develop medical transition plan covering: - Medication administration protocols - Medical equipment transfer - Emergency procedures - Specialized care routines - Provider contact information
  2. Train receiving caregivers
 30 days before discharge Medical transition plan T3C Blueprint p.124-125
Behavior Specialist
  1. Create behavior support transition package: - Current behavior plans with data - Sensory accommodation guide - Communication strategies/tools - Visual supports inventory - Environmental modification needs - Daily routine schedules
  2. Provide hands-on training
 14 days before discharge Behavior support package T3C Blueprint p.129
Aftercare Case Manager
  1. Establish mandatory IDD/Autism schedule: - Twice-monthly contact (minimum) - Communication method preferences - RN consultation availability - Behavior monitoring tools - Skills maintenance tracking
  2. Coordinate with regional IDD services
 7 days before discharge IDD-specific plan MANDATORY: T3C Blueprint p.134
Aftercare Case Manager
  1. Maintain family/caregiver engagement post-discharge: - Twice-monthly contact with family/caregivers (minimum) - Consult on daily routines, sensory accommodations, and communication strategies - Verify implementation of behavior support plans and visual supports - Identify caregiver training gaps and arrange targeted support - Document all family engagement contacts
  2. Connect families to regional IDD support resources and parent training programs
 Ongoing post-discharge; begin coordination 7 days before discharge Family Engagement Log; IDD-specific plan FC7-01 IDD Aftercare Family Engagement; T3C Blueprint p.134

2.4 ☒ Substance Use Support Services Enhanced Planning

Who How When Where Regulatory Reference
Therapist/Substance Use Counselor
  1. Prepare treatment transition summary covering: - Current treatment modality and progress - Medication-assisted treatment (MAT) status if applicable - Relapse prevention plan with triggers identified - Recommended ongoing treatment level - Provider recommendations for receiving area
  2. Coordinate warm handoff to receiving provider
 30 days before discharge Treatment transition summary T3C Blueprint; FC-SU-01
Case Manager
  1. Identify community recovery resources: - 12-step or alternative recovery programs - Peer support networks - Recovery community organizations - Sober living connections if applicable
  2. Facilitate introductions before discharge
 14 days before discharge Recovery resource plan T3C Blueprint; FC-SU-01
Aftercare Case Manager
  1. Establish mandatory service schedule: - Twice-monthly contact (minimum) - First month: in-person preferred - 24/7 relapse crisis availability - Recovery stability monitoring - Treatment engagement tracking
  2. Document in aftercare plan
 7 days before discharge Aftercare service plan MANDATORY: T3C Blueprint (MH pattern)
Aftercare Case Manager
  1. Maintain family/caregiver engagement post-discharge per FC7-01: - Twice-monthly contact with family/caregivers (minimum) - Support ongoing connections between youth and biological family, relatives, and other identified supportive persons - Consult on recovery-supportive family dynamics and communication strategies - Identify family barriers to recovery support and address proactively - Document all family engagement contacts in aftercare service records
  2. Connect families to community family support and recovery education resources
 Ongoing post-discharge; begin coordination 7 days before discharge Family Engagement Log FC7-01 Family Connections and Engagement; FC-AF-01 §SU Item 10; T3C Blueprint

2.5 Add-On Services Aftercare Planning

Purpose and Overview

Three T3C Add-On Services — Kinship Caregiver Support Services, Pregnant & Parenting Youth Support Services, and Youth Transition Support Services — each carry mandatory 6-month aftercare requirements with service-specific contact schedules. Each Add-On's combined policy and procedure document contains its own aftercare planning and delivery procedures. This section provides the cross-cutting overview and contact schedule reference; staff must follow the detailed procedures in the applicable Add-On document.

Add-On Service Aftercare Procedure Reference Contact Schedule Monthly Reporting
Kinship Caregiver Support Services FC-KIN-01.1 §16 Months 1–3: Weekly; Months 4–6: Twice monthly End of each month to SSCC/DFPS
Pregnant & Parenting Youth Support Services FC-PPY-01 §12 Weeks 1–4: Weekly; Months 2–6: Bi-weekly By 5th of each month to SSCC/DFPS
Youth Transition Support Services FC-YT-01 §13 Month 1: Weekly; Months 2–3: Bi-weekly; Months 4–6: Twice monthly End of each month to SSCC/DFPS

Planning timelines:

Note: When a youth is receiving both a base package (e.g., MH, IDD, SU) and an Add-On service, the more intensive aftercare contact schedule applies. Aftercare staff must coordinate obligations across both the base package and Add-On aftercare requirements.

3. AFTERCARE SERVICE DELIVERY

Purpose and Overview

Consistent, quality aftercare service delivery supports successful transitions and prevents placement disruptions. This section details the specific services provided and contact requirements for each package.

3.1 Contact Requirements and Methods

Service Package Minimum Frequency Preferred Methods Crisis Response
Basic Foster Care Monthly Phone, video, in-person per youth preference Business hours + referral
Mental & Behavioral Health TWICE MONTHLY In-person month 1, then flexible 24/7 availability required
IDD/Autism TWICE MONTHLY Based on communication needs 24/7 RN consultation
Substance Use Support Services TWICE MONTHLY In-person month 1, then flexible 24/7 relapse crisis response
Treatment Foster Care Weekly (month 1), then twice monthly In-person for prevention 24/7 availability required
Kinship Caregiver Add-On Months 1–3: WEEKLY; Months 4–6: TWICE MONTHLY Phone or in-person; flexible scheduling including evenings/weekends As needed; 24/7 on-call (FC-KIN-01.1 §2.5)
Pregnant & Parenting Youth Add-On Weeks 1–4: WEEKLY; Months 2–6: BI-WEEKLY Per youth and child's schedule Within 24 hours of parenting crisis
Youth Transition Add-On Month 1: WEEKLY; Months 2–3: BI-WEEKLY; Months 4–6: TWICE MONTHLY Phone, text, email, or in-person per youth preference As needed

3.2 Core Service Components

Who How When Where Regulatory Reference
Aftercare Case Manager
  1. Document every contact and every attempted contact using the Contact Documentation Form including: - Date, time, duration of contact (or attempted contact and method of attempt) - Method of contact (in-person, phone, video, text, email) - Whether the contact was successful or attempted-only; if attempted-only, the reason (no answer, no response, voicemail left, etc.) and the next attempt scheduled - Topics discussed - Progress indicators - Concerns identified - Actions taken - Next steps planned
  2. Upload to Radius and to the youth's case record within 24 hours
  3. Feed the Aftercare Tracking Dashboard (once live — see §3.5) for cross-site oversight by the Regional Youth Stability Coordinator
 Per package schedule above; every attempted contact logged at the time of attempt Contact Documentation Form (previewforms.refugehouse.org); Radius; youth case record T3C Blueprint aftercare requirements
Aftercare Case Manager
  1. Document referrals generated during aftercare: - Referrals to continued therapy, psychiatric care, medical/dental, substance use treatment, MAT, educational supports, housing, employment, benefits, and any package-specific services - For each referral: provider name, contact information, service requested, referral date, status (pending, accepted, declined, completed), and follow-up plan
  2. File in the youth's case record and Radius
 At the time of each referral Referral Log section of Contact Documentation Form T3C Blueprint
Aftercare Case Manager
  1. Document case management support activities including: - Resource navigation and advocacy (housing, benefits, employment) - Coordination across providers (warm handoffs, three-way calls, meeting facilitation) - Family/caregiver support coaching - Crisis prevention and de-escalation support - Transportation arrangement - Court-related coordination
  2. Maintain in the youth's case record
 Per contact and per package schedule Case Management Support section of Contact Documentation Form TAC §749.503; T3C Blueprint
Aftercare Case Manager
  1. Provide crisis intervention: - Complete crisis assessment section of Contact Documentation Form - Document safety plan activation - Record intervention strategies used - Note resources mobilized - Plan follow-up within 24 hours
  2. Notify supervisor if hospitalization needed
 Within 2 hours of crisis notification (24/7 for specialized packages) Crisis section of Contact Documentation Form T3C Blueprint aftercare requirements
Aftercare Case Manager
  1. Coordinate services including: - Medical appointments - Educational support - Housing assistance - Employment services - Benefits enrollment - Transportation
  2. Track service engagement
 Ongoing throughout aftercare period Service coordination log TAC §749.503

Documentation custody and transmission:

All aftercare documentation — contacts, attempted contacts, referrals, case management support entries, crisis intervention records, and service coordination logs — is maintained in the youth's case record (in Radius and in the physical/digital case file). A consolidated monthly aftercare report (see §5.2 SSCC/DFPS Reporting) is generated from this documentation and provided to the SSCC or DFPS caseworker no later than 3 business days after the end of each month (i.e., a monthly cadence anchored on the end-of-month boundary, with the report transmitted within the first 3 business days of the following month). This satisfies the T3C Blueprint aftercare requirement that documentation be maintained in the case record and a copy provided to SSCC/DFPS monthly.

3.3 Package-Specific Service Delivery

Mental & Behavioral Health Services
Who How When Where Regulatory Reference
Licensed Therapist 1. Provide clinical consultation: - Treatment team participation - Caregiver coaching - Crisis intervention support - Medication monitoring input - Relapse prevention planning Minimum monthly, as needed for crises Consultation notes T3C Blueprint p.86
Aftercare Case Manager
  1. Monitor mental health indicators: - Therapy attendance - Medication compliance - Psychiatric stability - Crisis frequency - Hospitalization needs
  2. Coordinate with STAR Health
 During each contact Clinical tracking T3C Blueprint p.78-93
IDD/Autism Services
Who How When Where Regulatory Reference
RN Consultant 1. Provide medical consultation: - Medication administration support - Equipment troubleshooting - Medical protocol adjustments - Emergency guidance - Health status review 24/7 availability, scheduled monthly reviews Medical consultation log T3C Blueprint p.134
Aftercare Case Manager 1. Support developmental needs: - Behavior plan implementation - Sensory accommodation verification - Communication system support - Routine maintenance assistance - Skills generalization tracking During each contact Developmental tracking T3C Blueprint p.124-135
Substance Use Support Services
Who How When Where Regulatory Reference
Aftercare Case Manager
  1. Monitor recovery stability indicators: - Treatment appointment attendance - Recovery meeting participation - Support network engagement - School/work functioning - Absence of substance use indicators
  2. Document progress and concerns
 During each contact Recovery monitoring form T3C Blueprint; FC-SU-01
Aftercare Case Manager 2. Support recovery environment: - Verify receiving placement maintains substance-free environment - Provide education on recovery-supportive approaches - Coach caregivers on non-punitive relapse response - Assist with medication storage/administration protocols if MAT Monthly minimum Placement support documentation T3C Blueprint; FC-SU-01
Aftercare Case Manager 3. Coordinate ongoing treatment: - Verify treatment appointments scheduled - Monitor STAR Health authorization status - Facilitate provider communication - Adjust services as recovery needs change Ongoing Treatment coordination log FC10-01.2

3.4 Substance Use Relapse Crisis Response

Who How When Where Regulatory Reference
Crisis Management Staff 1. Receive relapse crisis call: - Assess immediate safety - Determine severity of relapse - Evaluate need for medical intervention - Document initial assessment Immediately upon notification Crisis documentation Crisis Management Staffing Plan
Aftercare Case Manager 2. Implement relapse response protocol: - Contact receiving placement within 2 hours - Assess placement stability - Coordinate with treatment provider - Develop immediate support plan - Approach as treatment issue, NOT punishment Within 2 hours of notification Relapse response documentation FC-SU-01 Section 14
Treatment Director (Consultation) 3. Provide clinical guidance: - Review relapse circumstances - Recommend treatment adjustment - Assess need for higher level of care - Approve safety planning modifications Within 24 hours Clinical consultation note T3C Blueprint
Aftercare Case Manager 4. Implement post-relapse support: - Increase contact frequency temporarily - Coordinate treatment intensification - Support placement preservation - Document all interventions Ongoing per clinical need Case notes FC-SU-01

CRITICAL: Relapse is treated as a clinical/treatment issue requiring adjustment, NOT as a behavioral violation or failure. Non-punitive, recovery-supportive approach is mandatory.

3.5 Aftercare Tracking Dashboard

Purpose and Overview

The Aftercare Tracking Dashboard is a centralized, automated monitoring tool that aggregates aftercare contacts, attempted contacts, referrals, case management support entries, and service-engagement data across all packages and both sites (Dallas and San Antonio). It provides the Regional Youth Stability Coordinator (RYSC), Aftercare Coordinator, and Program/Treatment Directors with a real-time operational view of aftercare compliance and youth-level outcomes, and feeds the monthly SSCC/DFPS report described in §5.2.

Implementation Status: Planned — active build during the Inactive Interim Credential period; target activation: Q1 of the Active Interim Credential period, coinciding with Heather Sartin's transition into the Regional Youth Stability Coordinator role. Until the Dashboard is live, the underlying data is captured in Radius and the youth case record per §3.2; the Dashboard adds aggregation, exception flagging, and reporting automation on top of that existing source-of-truth documentation.

3.5.1 What the Dashboard Captures
Data element Source Refresh cadence Used by
Scheduled vs. completed contacts (per youth, per package, per contact-schedule requirement) Contact Documentation Form (Radius) Real-time on upload RYSC, Aftercare Coordinator, Program Director
Attempted-only contacts and next-attempt scheduling Contact Documentation Form Real-time RYSC for follow-up escalation
Referrals issued, with status (pending, accepted, declined, completed) and follow-up dates Referral Log section of Contact Documentation Form Real-time RYSC, Aftercare Coordinator
Case management support activities Case Management Support section of Contact Documentation Form Real-time RYSC, Aftercare Coordinator
Crisis incidents and intervention outcomes Crisis section of Contact Documentation Form Real-time; flagged for Treatment Director review on Level 2+ Treatment Director, RYSC
Service engagement indicators (therapy attendance, treatment adherence, recovery stability where applicable) Therapy/treatment provider records via STAR Health coordination Weekly batch RYSC, Treatment Director
6-month aftercare period clock (days elapsed, days remaining, anticipated closeout date) Aftercare eligibility module (Radius) Real-time Aftercare Coordinator
Exceptions (missed contact requirements, overdue referrals, late documentation uploads) Computed from above Real-time RYSC for proactive outreach to outbound CMs
3.5.2 Roles and Responsibilities
Who Role with respect to the Dashboard
Outbound-transitioning Case Manager (acting as Aftercare Case Manager per §2.0.1) Source-of-truth feeder: completes every Contact Documentation Form entry — including attempted contacts, referrals, case management support, crisis records — in Radius within 24 hours, which automatically populates the Dashboard.
Aftercare Coordinator (Regional Youth Stability Coordinator / RYSC) Operational and reporting owner: the same role described in §2.0.1 and in the Aftercare Coordinator Job Description. Monitors compliance exceptions on the Dashboard, escalates overdue or missed-contact patterns to outbound CMs and to the Program Director, runs the monthly aggregation that feeds the SSCC/DFPS report, maintains the Dashboard's exception-rule configuration, authorizes additional meetings/staffings/referrals when patterns indicate need, and recommends CM reassignment to the Program Director when continuity breaks. Heather Sartin holds this role at Q1 Active Interim Credential.
Treatment Director Clinical reviewer: receives flagged crisis records and treatment-engagement exceptions for MH/IDD/SU/TFFC cases; consults on clinical adjustments.
Program Director Supervisory authority over the Aftercare Coordinator; approves CM reassignment when escalated by the Coordinator; reviews and approves the monthly aftercare report to SSCC/DFPS; receives the leadership summary.
Executive Director Strategic oversight: receives monthly Dashboard summary; uses outcomes in CQI cycles and leadership review.
3.5.3 Integration with Monthly SSCC/DFPS Reporting

The monthly aftercare report generated for SSCC/DFPS (see §5.2) is derived directly from the Dashboard once live. Until activation, the same report is compiled manually from Radius and Contact Documentation Forms. The Dashboard does not replace the case record as the documentation source of truth — it aggregates and reports on it. The youth's case record (Radius entries + supporting documentation) remains the authoritative record for compliance audits and DFPS inspections.

3.5.4 Implementation Milestones
Milestone Target Status
Functional spec — fields, exception rules, integrations, RYSC user roles End of Inactive Interim Credential period In development
Radius integration build (read Contact Documentation Form data into Dashboard) Inactive Interim Credential period In development
RYSC role activation (Heather Sartin transition) and Dashboard pilot launch Q1 Active Interim Credential Planned
Dashboard-derived monthly SSCC/DFPS report (replaces manual compilation) Q1 Active Interim Credential Planned
Cross-site full activation (both Dallas and San Antonio aftercare cases on the Dashboard) Q2 Active Interim Credential Planned

4. 90-DAY CONTINUED STAY REVIEWS

Purpose and Overview

For Mental Health and IDD/Autism packages, the 90-day continued stay review process ensures children receive appropriate levels of care throughout their placement, with mandatory aftercare planning integrated into each review.

4.1 Review Process for Specialized Packages

Who How When Where Regulatory Reference
Treatment Director
  1. Complete comprehensive review using Service Plan T3C Supplement (FC3-03): - CANS 3.0 reassessment results section - Continued Stay Evaluation section - Treatment progress indicators - Crisis incident summary - Family engagement progress
  2. Determine continued need for specialized services
 Every 90 days from admission Service Plan T3C Supplement Form (FC3-03) CRITICAL: T3C Blueprint p.78, p.124
Program Director
  1. Provide written confirmation stating: "Based on review, [Child's Name] continues to require [Service Package] and a less restrictive placement is not appropriate"
  2. Include supporting data
  3. Sign and date confirmation
 Within 48 hours of review Confirmation form CRITICAL: T3C Blueprint requirement
Case Manager
  1. Compile review package including: - Both Director confirmations - Review meeting notes - Updated service plan - CANS results - Aftercare planning updates
  2. Submit to SSCC/DFPS
 Within 15 business days of review IMPACT submission CRITICAL DEADLINE

5. MONITORING AND REPORTING

Purpose and Overview

Systematic monitoring ensures service quality, regulatory compliance, and continuous improvement while providing required reports to oversight agencies.

5.1 Progress Monitoring

Who How When Where Regulatory Reference
Aftercare Case Manager
  1. Track key indicators: - Contact compliance rate - Service engagement level - Placement stability status - Crisis incident frequency - Goal achievement progress
  2. Identify trends and concerns
 Ongoing with monthly summaries Radius tracking module T3C Blueprint requirements
Aftercare Coordinator
  1. Review all cases for: - Regulatory compliance - Service effectiveness - Documentation quality - Emerging patterns - Resource needs
  2. Provide feedback to staff
 Monthly Quality review reports TAC §749.131

5.2 SSCC/DFPS Reporting

The monthly aftercare report compiles, for each youth in aftercare, the documentation maintained in the youth's case record per §3.2 — every contact, every attempted contact, every referral (with status), case management support activities, crisis incidents, and progress indicators. The report is derived from the Aftercare Tracking Dashboard once live (see §3.5); until activation, it is compiled manually from Radius and the Contact Documentation Forms.

Cadence: The report covers each completed calendar month (1st through last day of month) and is transmitted to SSCC/DFPS no later than 3 business days after the end of the reporting month.

Who How When Where Regulatory Reference
Aftercare Case Manager (outbound-transitioning CM acting as Aftercare CM per §2.0.1)
  1. Confirm every contact and attempted contact for the month is logged in Radius / Contact Documentation Form
  2. Confirm every referral and case management support activity is logged
  3. Generate or pull the monthly aftercare summary for each assigned youth
 By 1st business day of the following month Radius; Contact Documentation Form; (once live) Aftercare Tracking Dashboard T3C Blueprint aftercare requirements; §3.2 documentation custody
Aftercare Coordinator (Regional Youth Stability Coordinator / RYSC — Heather Sartin at Q1 Active Interim)
  1. Aggregate per-youth reports into the cross-site monthly aftercare report (sends reminder emails to CMs by 2nd of month per the Aftercare Coordinator JD; follows up with any missing submissions by the 4th)
  2. Verify exception flags from the Dashboard are addressed or noted; document findings and recommendations from the 10% random audit
  3. Maintain log of submissions and SSCC/DFPS acknowledgments; escalate persistent non-compliance to the Program Director
  4. Forward consolidated report to Program Director for approval
 By 2nd business day of the following month Aftercare Tracking Dashboard (once live); manual aggregation pre-Dashboard T3C Blueprint; Aftercare Coordinator JD
Program Director
  1. Review and approve the monthly aftercare report
  2. Ensure accuracy and completeness
  3. Add executive summary highlighting trends, exceptions, and case-specific concerns
  4. Transmit to SSCC/DFPS — a copy is filed in each youth's case record and archived in Radius
 By 3rd business day of the following month IMPACT portal (primary); email backup to assigned SSCC/DFPS caseworker; Radius archive of transmitted report TAC §749.361; T3C Blueprint aftercare requirements

Substance Use Package-Specific Monthly Report Elements:

Element Description Responsible
Recovery stability status Overall assessment of recovery progress Aftercare Case Manager
Treatment engagement Attendance and participation in substance use treatment Aftercare Case Manager
Relapse incidents Any relapse events and response actions taken Aftercare Case Manager
Recovery support connections Status of community recovery resource engagement Aftercare Case Manager
MAT coordination (if applicable) Medication compliance and provider coordination Aftercare Case Manager
Placement preservation status Assessment of placement stability and any concerns Aftercare Case Manager

6. AFTERCARE COMPLETION

Purpose and Overview

Proper closure of aftercare services ensures youth have sustainable supports in place and celebrates their successful transition.

6.1 Completion Assessment

Who How When Where Regulatory Reference
Aftercare Case Manager
  1. Conduct completion assessment: - Goal achievement review - Support sustainability check - Resource adequacy evaluation - Youth satisfaction survey - Caregiver feedback
  2. Determine readiness for closure
 At month 5 of aftercare Completion assessment form T3C Blueprint requirements
Treatment Team (Mental Health/IDD)
  1. Review clinical indicators: - Stability maintenance - Crisis absence - Service engagement - Medication compliance - Natural support strength
  2. Recommend closure or extension
 30 days before 6-month mark Clinical review T3C Blueprint p.86, p.134
Program Director
  1. Approve service: - Successful completion - Extension (with justification) - Transfer to adult services
  2. Document decision rationale
 Before 6-month deadline Closure documentation T3C Blueprint aftercare requirements

Substance Use Package-Specific Completion Indicators:

Indicator Target Assessment Method
Sustained recovery No relapse in final 60 days Case documentation review
Treatment engagement Consistent attendance throughout 6 months Treatment provider verification
Recovery support network Established community connections Youth self-report + case notes
Caregiver competency Receiving placement demonstrates recovery-supportive approach Caregiver assessment
Crisis plan in place Written relapse response plan with receiving placement Documentation review

7. QUALITY ASSURANCE

Purpose and Overview

Continuous quality improvement ensures aftercare services achieve intended outcomes and maintain compliance with all regulatory requirements.

7.1 Quality Monitoring

Who How When Where Regulatory Reference
QA Coordinator
  1. Monitor quality indicators: - Contact compliance (Target: 95%) - Crisis response time (Target: 2 hours) - Report timeliness (Target: 100%) - Documentation quality - Youth satisfaction
  2. Generate performance reports
 Monthly QA dashboard TAC §749.131
Aftercare Coordinator
  1. Analyze aggregate outcomes: - Placement stability rates - Re-entry prevention - Service effectiveness - Cost per case - Success predictors
  2. Identify improvement opportunities
 Quarterly Outcome analysis T3C Blueprint requirements
Leadership Team
  1. Review findings and implement improvements: - Resource allocation - Training needs - Process refinements - System enhancements - Policy updates
  2. Celebrate successes
 Quarterly Leadership minutes TAC §749.131

REGULATORY REFERENCES

FORMS/ATTACHMENTS

Core Forms (All Packages):

Package-Specific Forms:

Mental & Behavioral Health Support Services:

IDD/Autism Spectrum Disorder Support Services:

T3C Treatment Foster Family Care:

Substance Use Support Services:

Add-On Services (see Add-On combined documents for full forms lists):

Quality Assurance Forms:

This procedure document operationalizes the principles established in the corresponding policy 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.

© 2026 Refuge House, Inc. · This is a controlled document. Always refer to the current version.