Community-Based Care Coordination
Care Coordination Standards
Engage
Assess
Support
Connect
Purpose
Reach and build relationships with people in communities who have complex needs and want support to improve their health
Identify the social conditions that significantly compromise a client’s health and identify services a client might be eligible for
Co-develop a care plan that addresses the client’s goals and nurtures their belief and ability to meet these goals
Assist the client to access community resources and clinical services
Steps
- Establish trust with community
- Outreach & engagement
- Offer services
- Obtain consent
- Document
- Complete intake
- Assess social conditions
- Check for eligibility
- Make it a conversation to maintain trust
- Document
- Develop client-centered care plan
- Encourage client progress
- Educate
- Advocate
- Engage care team
- Document
- Locate social & health services
- Offer services
- Support client & provider readiness
- Complete closed loop referrals
- Close client case
- Document