i. Health care provider (medical, mental health, SUD) ii. Medications iii. Overdose prevention iv. Alcohol and drug health education v. Sexual/reproductive health education and planning vi. HIV prevention. If the patient’s HIV status is not known, they should be offered testing for HIV infection. If the patient is at risk for acquiring HIV in the community (e.g., sexual partner with HIV, injection partner with HIV), they should receive education about reducing risk and be offered pre-exposure prophylaxis (PrEP medications) as part of their release medications. vii. Nutrition viii. Self-care for chronic medical conditions e. Develop an action plan for release based on a prioritized list of needs generated with the patient’s input and resulting in “to-do” lists for the patient and discharge planning staff. f. Obtain the patient’s contact information in the community (and alternatives such as family and friends). g. Obtain the patient’s signature on appropriate release of information forms to assist in communicating with community providers. h. Arrange facilitated referrals to the services (in the community reentry guide) matching the needs identified through the needs assessment. i. Arrange with the local health department for any follow-up needed for infectious diseases that require continuing health department involvement (e.g., tuberculosis). i. Schedule the first post-release health care appointment as soon as possible, ideally within 48 hours of release. j. Arrange for transfer of health records or a medical summary of key information (e.g., current problem list, medications, test results, pending workup or follow-up needs)...
