2507.1 Care Coordination is the facilitation or 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, but is not limited to, the facilitation or implementation of the following:

(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 and other electronic 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;

(l) Coordination with other health care providers to ensure screenings follow-up is completed;

(m) Coordinating with Fire and Emergency Medical Services to promote appropriate utilization of emergency medical and transport services; and

(n) Ensure that consumers continue connections to and maintain eligibility for any public benefit to which the beneficiary may be entitled, including Medicaid.

SOURCE: Final Rulemaking published at 63 DCR 849 (January 22, 2016); as amended by Final Rulemaking published at 66 DCR 5625 (May 3, 2019).