Standards for public agencies

2020 Edition

Integrated Care; Health Homes (PA-ICHH) 5: Care Planning and Monitoring

The person and his or her family participate in the development and ongoing monitoring of a care plan that is the basis for delivery of appropriate services and support.
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
  • Service planning and monitoring procedures 
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

PA-ICHH 5.01

An assessment-based care plan is developed in a timely manner with the full participation of the individual and his or her family and includes: 
  1. the person's behavioral health, physical health, and community and social support service needs and goals, including basic needs when applicable; 
  2. steps for working toward achievement of desired goals including timeframes where appropriate;
  3. services and supports to be provided, and by whom; 
  4. possibilities for maintaining and strengthening family relationships and other informal social networks;
  5. agreed upon timelines for conducting regular case reviews; and 
  6. documentation of the individual’s or family’s involvement in care planning.

PA-ICHH 5.02

The care coordinator and the care planning team actively review the case according to established timelines to assess:
  1. continued accuracy of the assessment;
  2. care plan implementation;
  3. the person’s continued engagement in his or her treatment;
  4. the person’s progress toward achieving goals and desired outcomes; and
  5. the continuing appropriateness of agreed upon service goals.


Timeframes for the review should be defined by the person and the care coordinator and take into consideration the issues and needs of the person and the frequency and intensity of services provided. Traumatic events or other significant life changes such as changes in housing, disclosure of abuse, hospitalization, or contact with the criminal justice system should trigger an immediate review of the case.

PA-ICHH 5.03

The care coordinator, the individual, and his or her family:
  1. regularly review progress toward achievement of agreed upon goals; and  
  2. sign revisions to service goals and plans.