Domain 1: Screening, Identification & Assessment
The foundation for effective, high-quality and Holistic Care Coordination (HCC) is ensuring the needs of those you are serving are met. A variety of screening tools can help identify who may benefit from care coordination. Once identified, assessing one's needs is a continuous process that focuses on conversations with the individual or their family about their needs, preferences, strengths, barriers and priorities.
Screen to identify care coordination need.
- Organized and timely. Screening should be organized, timely and well documented. It should include information from medical records, other providers, education records and records from other systems (see Standards 1.1 and 1.2 for more information).
- Strengths based and comprehensive. The screening process should include multiple factors including but not limited to: family strengths and resiliency; individual's health status and any limitations; potential barriers to services; social determinants of health; and family beliefs, preferences, needs and goals (see Standard 1.3 for more information).
- Integrate alongside other screenings. Screening for care coordination should take place in addition to other assessments that occur during enrollment into a health plan (see Standard 1.6 for more information).
- Offer opt-out options. Best practice holds that all individuals served receive screening; however, individuals or families should always be provided an option to opt out of further assessment and care coordination services (see Standard 1.4 for more information).
Assess intensity of care coordination need.
- Establish relationships. Identify strengths and needs through trusting relationships. Further assessment for care coordination should build from conversations with the individual or family to identify strengths and needs, taking into consideration health status and history and other key pieces of the individual's life (see Standards 1.5 and 1.7 for more information).
- Assess then act. Assessing the need for care coordination should lead to an action-oriented shared plan of care (see Domain 2). This includes identifying the referral and connection needs of the individual or family, as well as looking to the future for goal setting opportunities and risks for adverse outcomes (see Standards 1.8, 1.9, and 1.11 for more information).
- Sharing is caring. Assessment results must be documented and shared with the individual or family. Make sure to get appropriate consents so you can share with other members of the care team. This supports continuity of care and services and reduces burden on the individual or family, as well as other providers (see Standard 1.10 for more information).
- Reassess regularly. All individuals and families should be reassessed for care coordination services at least every six months or when significant changes in the individual's life occur (see Standards 1.12 and 1.13 for more information).
Evaluate care coordination services.
- Evaluate satisfaction. Establish a tool for evaluating and gauging individual or family satisfaction with your care coordination efforts (see Standard 1.8 for more information).
- Monitor referrals. Connection to services in the community and within health care should be tracked and documented to identify the biggest referral points to strengthen and streamline processes to reduce burden for families (see Standard 1.9 for more information).