(b) The model care coordination plan and process shall outline who will be on the care team and how the communication will occur to coordinate care. It shall specify that the care coordination is a shared responsibility between, at a minimum, the county, the facility, and the health care payer, if different from the county. The model care coordination plan shall, at a minimum, also address the following:

1. (1) The roles of each entity to ensure continuity of services and care for all individuals exiting involuntary holds, including how referrals will be made and appointments will be scheduled pursuant to subdivision (d) of Section 5008. This shall include all of the following:

   1. (A) Identification of county resources, programs, and contact information to facilitate referrals for individuals exiting involuntary holds or intensive treatment, including, but not limited to, suicide prevention, substance use disorder treatment, Medi-Cal Enhanced Care Management, Full Service Partnerships, assisted outpatient treatment, early psychosis intervention services, and resources published pursuant to Section 5013.
   2. (B) Hospital aftercare and discharge planning processes pursuant to Sections 1262 and 1262.5 of the Health and Safety Code.
   3. (C) Hospital policies and procedures in compliance with nationally accepted accreditation standards to reduce the risk of suicide, including, but not limited to, screening and assessing patients for suicidal ideation and suicidal risk, developing a safety plan with patients at risk for suicide, and following written policies and procedures addressing the care, counseling, and followup care at discharge for patients at risk for suicide.
2. (2) A requirement that the care coordination plan for an individual exiting a temporary hold or a conservatorship include a detailed plan that includes a scheduled first appointment with the health plan, the mental health plan, a primary care provider, or another appropriate provider to whom the person has been referred.
3. (3) County procedures and contact information for the availability of designated persons for the purpose of conducting an assessment pursuant to Section 5150. Designated individuals shall be available on a 24-hours-per-day, seven-days-per-week basis in order to ensure that individuals are released from the hold as soon as possible after it is determined they no longer require detention. In no event may the individual be involuntarily held beyond when they would otherwise qualify for release.
4. (4) County procedures for facilities and professional persons to request designation to perform assessments and evaluations, pursuant to Sections 5151 and 5152.
5. (5) County procedures and contact information facilities are required to use to obtain an assessment and evaluation of an individual, pursuant to Sections 5151 and 5152.
6. (6) Defined expectations for information sharing, including notification of and transmittal of applications pursuant to Section 5150 and plans to periodically convene to identify and resolve challenges.

(c)

1. (1) Each county mental health department shall ensure that a care coordination plan that ensures continuity of services and care in the community for all individuals exiting holds or a conservatorship pursuant to this part is established.
2. (2) All facilities designated by the counties for evaluation and treatment under this part shall implement the model care coordination plan on or before August 1, 2024.
3. (3) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the State Department of Health Care Services may implement Section 5402.5 by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking any further regulatory action.