Coordination of Care

Standard Assessment
1. A system is in place to ensure coordination of mental health care for clients among the providers of psychiatric and psychotherapeutic services.
  1. There are written policies and procedures on inter- and intra-agency collaboration with other mental health providers.
  2. The clinical team includes staffing resources dedicated to ensuring multidisciplinary care coordination regularly occurs.
  3. Client charts include summary information from other mental health providers, as appropriate.
  4. Client charts reflect evidence of case conferencing with involved mental health providers.
  5. Client charts reflect evidence of coordination and follow up for those clients who have difficulty remaining engaged in treatment.
2. A systems is in place to ensure coordination of mental health care with primary care, case management, harm reduction, substance use treatment, social and legal services, rehabilitation and self-help programs, as appropriate.
  1. There are written policies and procedures regarding care coordination with other service providers.
  2. The primary medical provider is identified in each client record.
  3. Mental health care is coordinated with other internal and external services, including primary care, case management, harm reduction, substance use services, social and legal services, rehabilitation and self-help programs.
  4. There is evidence of effective referral relationships for the full range of services necessary to improve health outcomes, including:
    • Primary care
    • Mental health
    • Case management (including COBRA, community based and medical case management programs)
    • Harm reduction
    • Substance use treatment
    • Criminal justice
    • Social and legal services, and self-help programs as appropriate
  5. The mental health program coordinates services with other programs serving PLWHAs, including the Ryan White HIV Care Network(s) in the proposed service delivery area(s) and Special Needs Plans (if applicable).
  6. Client charts reflect evidence of case conferencing with providers of other systems of care, as appropriate.
  7. Patient records include summary information from other service providers, as appropriate.
  8. Appropriate releases (HIV/AIDS, mental health and substance use) are on file in the client chart for any incoming and outgoing patient information.