Standards for public agencies

2020 Edition

Integrated Care; Health Homes (PA-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.
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.
Note: Care coordination in this context includes coordination of any services provided directly by the agency as well as those provided through linkages to community providers.
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
  • Care coordination procedures
  • Care transition procedures
  • Procedures for conducting or tracking medication reconciliation and adherence
  • Copy of agreement with and/or job description and resume for each member of the care planning team, including a physician and psychiatrist for consultation
  • Copies of agreements with community providers, as applicable 
  • Community resource and referral list


  • Interviews may include:
    1. Program director 
    2. Relevant personnel
    3. Persons served 
  • Review case records

Fundamental Practice

PA-ICHH 6.01

The care planning team includes at a minimum: 
  1. a designated care coordinator with qualifications appropriate to the needs of the identified service population; 
  2. a primary care professional such as a physician’s assistant or nurse practitioner with access to a physician for needed consultation;  
  3. a behavioral health professional such as a social worker, psychologist, or other licensed clinician with access to a psychiatrist for needed consultation; and
  4. other providers and supports based on the needs of the individual.
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: Agencies 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.

PA-ICHH 6.02

The roles and responsibilities of each team member are clearly defined.

PA-ICHH 6.03

The agency facilitates access to the full array of community and social support, behavioral health care, and physical health care services by:
  1. establishing partnerships and coordination procedures with direct service providers in the community; 
  2. establishing communication procedures with persons served and across disciplines, both internally and externally;
  3. maintaining a comprehensive, up-to-date referral list;
  4. 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
  5. 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:
  1. preventative and health promotion services;
  2. mental health and substance use services;
  3. comprehensive care management, care coordination, and transitional care;
  4. chronic disease management, including self-management;
  5. community, social support, and recovery services; 
  6. peer support services; and
  7. long-term care supports and services.

PA-ICHH 6.04

Individuals are assisted in making appointments for needed or requested services, and the care coordinator follows up to: 
  1. ensure the service was received; 
  2. identify any needed follow-up; and 
  3. make needed changes to the care plan in partnership with the person and his or her family.

PA-ICHH 6.05

The care coordinator supports smooth transitions between care settings by: 
  1. coordinating information sharing and service provision with providers and the person; 
  2. developing, or supporting the development of, a comprehensive discharge or transition plan with steps for follow-up; and
  3. 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.

Fundamental Practice

PA-ICHH 6.06

The agency:
  1. conducts medication reconciliation and adherence; or
  2. tracks that it is being done by another provider as part of their care coordination activities.

PA-ICHH 6.07

Care coordination activities are documented in the case record, including: 
  1. linkages to community providers as well as completed follow-up; 
  2. communication with partnering providers both internally and externally; and 
  3. communication with the person.
Examples: Care coordination activities that are documented in the case record can also include sharing the results of screenings and diagnostic and laboratory testing.