D.C. Municipal Regulations (Last Updated: September 13, 2017) |
Title 22. HEALTH |
SubTilte 22-A. MENTAL HEALTH |
Chapter 22-A25. HEALTH HOME CERTIFICATION STANDARDS |
Section 22-A2507. CARE COORDINATION
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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.