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. 

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Screening, Identification & Assessment Video

  1. Screen
  2. Assess
  3. Evaluate

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). 

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