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Care Coordination Agreements and Care Transitions

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Care coordination agreements ensure quality care and establish protocols for supporting effective care transitions.

Care coordination agreements are effective tools for outlining the responsibilities of the participating providers, facilities, and services. These agreements ensure that responsibilities for care and service transitions are orderly and promote the highest quality of care possible. Agreements also include protocols and procedures for how information is shared among organizations.

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Requirements for Care Coordination Agreements

Certified community behavioral health clinics (CCBHCs) are required to have agreements establishing care coordination expectations with certain entities in the area served by the CCBHC. When those entities include inpatient psychiatric facilities, ambulatory and medical detoxification facilities, post-detoxification step-down services, residential programs, inpatient acute-care hospitals, emergency departments, hospital outpatient clinics, urgent care centers, or residential crisis settings, among other things, the agreement must provide for:

  • Transfer of medical records of services received from those providers, including prescriptions
  • Tracking of admission and discharge
  • Active follow-up after discharge
  • Coordination of specific services if the consumer presented as a potential suicide risk

To the extent necessary, agreements also should include any other expectations necessary to carry out the other requirements related to care transitions.

Care Transitions: Tracking and Follow-up

Certain tracking and follow-up is required in care transitions, and it should be documented.

CCHBCs should have protocols in place for tracking consumers who are admitted to emergency departments, inpatient and outpatient hospitals, detoxification, and residential and other settings. These protocols also apply when consumers are discharged, unless there is a formal transfer of care to a non-CCBHC entity.

Protocols and procedures must be in place for transitioning individuals from emergency departments, inpatient psychiatric, detoxification, and residential settings to a safe community setting. The CCBHC should establish protocols and procedures, including the transfer of medical records of services received; active follow-up after discharge; a plan for suicide prevention and safety, as appropriate; and a provision for peer services. Procedures should include shortened time lag between subsequent assessment and treatment.

Follow-up should occur as follows:

  • The CCBHC must make and document reasonable attempts to contact all CCBHC consumers who are discharged from these settings within 24 hours of discharge
  • For all consumers discharged from such facilities who presented to the facilities as potential suicide risks, there must be a plan for suicide prevention and safety, and to coordinate consent and follow-up services with the consumer within 24 hours of discharge, which continues until the individual is linked to services or assessed to be no longer at risk
  • As appropriate, peer services should be provided


With regard to any non-CCBHC providers who provide care or services to a CCBHC consumer, the CCBHC must make and document reasonable attempts to determine medications prescribed by those providers for CCBHC consumers. With proper consent, the CCBHC should also provide such information to other providers where necessary to ensure safe, quality care.

CCBHCs and Sharing Protected Health Information

A cornerstone of effective care coordination is the timely sharing of patient information that supports multiple providers being able to access information services and document care plan progress. This includes the demographic and care information that is included in the CCBHCs electronic medical record, as well as the medical and service records of other providers involved in coordinated care. CCBHCs should have in place a plan that addresses how best to improve care coordination with all designated collaborating organizations (DCOs) using health information technology (HIT).

However, CCBHCs have a responsibility to protect patient privacy and document the necessary requirements for shared health information as determined by state and federal privacy laws, including the Health Insurance Portability and Accountability Act (HIPAA) (PL 104-191). Learn more about HIPAA and health information privacy rules.

While providers often acquire a range of health information from consumers, family members, and others, consent from the consumer must be obtained before sharing of this information. In situations where the CCBHC is unable to obtain consent after reasonable attempts, these must be documented and periodically revisited.

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Last Updated

Last Updated: 03/16/2023