Integrated Care; Health Homes (ICHH) 6: Care Coordination
All aspects of the person’s treatment are coordinated and monitored in accordance with the care plan to ensure access to and coordination of needed behavioral health care, physical health care, and community and social support services.
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Examples: The qualifications of the designated care coordinator will vary given the needs of the identified service population. For adults with serious and persistent mental health conditions, for example, a medical professional such as a nurse practitioner may be preferred given the high prevalence of comorbid, chronic, physical health conditions present in this population. For children, however, where chronic medical conditions are far less common, the coordination of behavioral health care and linkages to community and social support services might best be carried out by a behavioral health practitioner with experience working with children and families.
Examples: Organizations can leverage alternative service delivery methods such as telehealth and telemental health when regional shortages of certain professional groups, such as psychiatrists, make in-person consultation impractical.
Examples: Supports that may also be included on the care planning team can include, but are not limited to, peer mentors and natural supports as appropriate to the needs of the individual.
The roles and responsibilities of each team member are clearly defined.
The organization facilitates access to the full array of community and social support, behavioral health care, and physical health care services by:
establishing partnerships and coordination procedures with direct service providers in the community;
establishing communication procedures with persons served and across disciplines, both internally and externally;
maintaining a comprehensive, up-to-date referral list;
removing barriers to the initiation of needed services including procedures for providing a warm hand off when needed services are provided directly by the program or on-site through a partnering provider; and
assisting the person with system navigation.
The array of community and social support services and behavioral and physical health care services that should be made available to persons served include:
preventative and health promotion services;
mental health and substance use services;
comprehensive care management, care coordination, and transitional care;
chronic disease management, including self-management;
community, social support, and recovery services;
peer support services; and
long-term care supports and services.
Individuals are assisted in making appointments for needed or requested services, and the care coordinator follows up to:
ensure the service was received;
identify any needed follow-up; and
make needed changes to the care plan in partnership with the person and his or her family.
The care coordinator supports smooth transitions between care settings by:
coordinating information sharing and service provision with providers and the person;
developing, or supporting the development of, a comprehensive discharge or transition plan with steps for follow-up; and
facilitating face-to-face interactions between providers, whenever possible.
Examples: Supported transitions can include, but are not limited to, transitioning from inpatient hospitalization, residential treatment, therapeutic group care, the juvenile justice system, foster care, and from pediatric to adult settings.
conducts medication reconciliation and adherence; or
tracks that it is being done by another provider as part of their care coordination activities.
Care coordination activities are documented in the case record, including:
linkages to community providers as well as completed follow-up;
communication with partnering providers both internally and externally; and