Standards for private organizations

2020 Edition

Integrated Care; Health Homes (ICHH) 4: Assessment

The person and his or her family participate in a comprehensive, strengths-based, individualized assessment to identify service needs and goals.
2020 Edition




Adults and children who receive integrated care experience improved health care quality, an improved client care experience, and improved clinical and non-clinical outcomes.
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • In a few rare instances, urgent needs were not prioritized; or
  • For the most part, established timeframes are met; or
  • Culturally responsive assessments are the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active client participation occurs to a considerable extent.
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Urgent needs are often not prioritized; or 
  • Services are frequently not initiated in a timely manner; or
  • Applicants are not receiving referrals, as appropriate; or 
  • Assessment and reassessment timeframes are often missed; or
  • Assessment are sometimes not sufficiently individualized; 
  • Culturally responsive assessments are not the norm, and this is not being addressed in supervision or training; or
  • Several client records are missing important information; or
  • Client participation is inconsistent; or
  • Intake or assessment is done by another organization or referral source and no documentation and/or summary of required information is present in case record. 
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • There are no written procedures, or procedures are clearly inadequate or not being used; or
  • Documentation is routinely incomplete and/or missing.  
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Assessment procedures
  • Copy of assessment tool(s)
  • Procedures for referring individuals to specialized screenings, assessments, or tests when needed
  • Community resource and referral list
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

ICHH 4.01

Persons served participate in an individualized, culturally and linguistically responsive assessment that is completed within established timeframes.


The Assessment Matrix - Private, Public, Canadian, Network determines which level of assessment is required for COA’s Service Sections. The assessment elements of the Matrix can be tailored according to the needs of specific individuals or service design.

ICHH 4.02

Assessments are conducted using a standardized assessment tool to identify: 
  1. basic needs including food, clothing and shelter;
  2. the person's behavioral health, physical health, and community and social support service needs and goals;
  3. history of trauma;
  4. relevant systems involvement;
  5. individual and family strengths, risks, and protective factors;
  6. natural supports and helping networks; and
  7. the impact of the individual’s health care needs on the family unit.
Examples: For organizations serving children, systems involvement can include education, child welfare, and juvenile justice.

ICHH 4.03

The assessment incorporates applicable information from a variety of sources, which include, but are not limited to: 
  1. the person; 
  2. the person’s family;
  3. medical and/or clinical case records;  
  4. the results of screening tools; 
  5. relevant content from assessments completed by partnering or referring providers;
  6. other providers; and 
  7. members of the care planning team.
Examples: Organizations can review assessments completed by partnering or referring providers to identify, for example:
  1. gaps in information;
  2. out-of-date information; and 
  3. information that can be used to minimize duplication of effort.

Fundamental Practice

ICHH 4.04

Assessment procedures include mechanisms to identify and respond to individuals or families in crisis including:
  1. giving priority to urgent needs and emergency situations;
  2. expedited care planning; 
  3. connecting the individual to more intensive services as needed; 
  4. facilitating the development of a safety and/or crisis plan; and
  5. contacting emergency responders as appropriate.

ICHH 4.05

The organization promptly provides or makes arrangements for specialized screenings, assessments, or tests as needed based on information collected during initial and ongoing assessments.