Section 22-A2507. CARE COORDINATION

 

2507.1Care Coordination is the implementation of the comprehensive care plan through appropriate linkages, referrals, coordination and follow-up to needed services and support. Care Coordination provides assistance with the identification of individual strengths, resources, preferences and choices.  Care Coordination is a function shared by the entire Health Home Team and may involve:

 

(a) Developing strategies and supportive mental health intervention for avoiding out-of-home placement and building stronger family support skills and knowledge of the consumer’s strengths and limitations;

 

(b) Providing telephonic reminders of appointments;

 

(c) Providing telephonic consults and outreach;

 

(d) Communicating with family members;

 

(e) Identifying outstanding items on patient visit summaries such as referrals, immunization, self-management goal support and health education needs;

 

(f) Assisting with medication reconciliation;

 

(g) Making appointments;

 

(h) Providing patient education materials;

 

(i) Assisting with arrangements such as transportation, directions and completion of durable medical equipment requests;

 

(j) Obtaining missing records and consultation reports;

 

(k) Participating in hospital and emergency room (ER) transition care; and

 

(l) Coordination with other health care providers. 

 

 

authority

Sections 5113, 5115, 5117 and 5118 of the Department of Behavioral Health Establishment Act of 2013, effective December 24, 2013 (D.C. Law 20-61; D.C. Official Code §§ 7-1141.02, 7-1141-04, 7-1141.06 and 7-1141.07 (2012 Repl.)).

source

Final Rulemaking published at 63 DCR 849 (January 22, 2016).