Standards for public agencies

2020 Edition

Integrated Care; Health Homes (PA-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.
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
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

PA-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.

PA-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 agencies serving children, systems involvement can include education, child welfare, and juvenile justice.

PA-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: Agencies 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

PA-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.

PA-ICHH 4.05

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