Standards for public agencies

2020 Edition

Mental Health and/or Substance Use Services (PA-MHSU) 9: Care Coordination

The agency coordinates services in order to promote continuity of care and whole-person wellness.


The standards in PA-MHSU 9 address the efforts an agency makes to promote information sharing and collaboration with the various systems touching a particular individual. Agencies are not required to provide integrated care to implement the standards in this section. Agencies that offer integrated behavioral health and primary care services (e.g., health homes) will complete the Integrated Care; Health Home (PA-ICHH) standards.
NA The agency provides Diagnosis, Assessment, and Referral Services only.
2020 Edition




Individuals and families who receive Mental Health and/or Substance Use Services improve social, emotional, psychological, cognitive, and family functioning and attain recovery and wellness.
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
  • Procedures for care coordination
  • Copies of agreements with cooperating service providers and/or community resource and referral list, as appropriate
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records


PA-MHSU 9.01

The agency works in active partnership with persons served to:
  1. ensure that they receive appropriate advocacy support;
  2. assist with access to the full array of services to which they are eligible; and
  3. mediate barriers to receiving coordinated services.

Fundamental Practice

PA-MHSU 9.02

Individuals with co-occurring mental health and substance use disorders receive coordinated treatment either directly or through active involvement with a cooperating service provider.


This standard is applicable to all programs regardless of the services offered. Agencies that only treat substance use disorders are expected to have the core capability to address co-occurring mental health conditions, and agencies that only treat mental health disorders are expected to have the core capability to address co-occurring substance use disorders.

Fundamental Practice

PA-MHSU 9.03

The agency supports the coordination of behavioral and physical health care to increase service recipients’ access to needed services by:
  1. providing referrals to identified primary care providers;
  2. communicating with the primary care doctor about treatment planning; and
  3. linking individuals to providers that can help them navigate the health care system.


PA-MHSU 9.04

In collaboration with the service recipient, the agency coordinates with, as needed: 
  1. the child welfare system;
  2. the juvenile justice system;
  3. courts; and
  4. the school system.


PA-MHSU 9.05

Care coordination activities include:  
  1. linkages to community providers, as well as completed follow-up when possible; 
  2. communication with partnering providers both internally and externally; and 
  3. communication with the service recipient.