2022 Edition

Mental Health and/or Substance Use Services (CA-MHSU) 9: Care Coordination

The organization coordinates services in order to promote continuity of care and whole-person wellness.


The standards in CA-MHSU 9 address the efforts an organization makes to promote information sharing and collaboration with the various systems touching the individual or family. Organizations are not required to provide integrated care to implement the standards in this section. 
NA The organization provides Diagnosis, Assessment, and Referral Services only.




Individuals and families who receive Mental Health and/or Substance Use Services improve social, emotional, psychological, cognitive, and family functioning to attain recovery and wellness.
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active client participation occurs to a considerable extent.
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Procedures for care coordination
  • Copies of agreements with cooperating service providers and/or community resource and referral list, as appropriate
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records


CA-MHSU 9.01

The organization works in active partnership with individuals and families to:
  1. ensure that they receive appropriate advocacy support;
  2. assist with access to the full array of services to which they are eligible; and
  3. mediate barriers to receiving coordinated services.

Fundamental Practice

CA-MHSU 9.02

Individuals with co-occurring mental health and substance use disorders receive coordinated treatment either directly or through active involvement with a cooperating service provider.


This standard is applicable to all programs regardless of the services offered. Organizations that only treat substance use disorders are expected to have the core capability to address co-occurring mental health conditions, and organizations that only treat mental health disorders are expected to have the core capability to address co-occurring substance use disorders.

Fundamental Practice

CA-MHSU 9.03

The organization supports the coordination of behavioural and physical health care to increase access to needed services by:
  1. providing referrals to identified primary care providers;
  2. communicating with the primary care doctor about treatment planning; and
  3. linking individuals to providers that can help them navigate the health care system.


CA-MHSU 9.04

In collaboration with individuals and families, the organization coordinates with, as needed: 
  1. the child protection system;
  2. the justice system;
  3. courts; and
  4. the school system.


Implementation of CA-MSHU 9.04 should include collaboration with the referral source when families are referred and mandated to receive services by an agency with statutory responsibility.


CA-MHSU 9.05

Care coordination activities include:  
  1. linkages to community providers, as well as completed follow-up when possible; 
  2. communication with partnering providers both internally and externally; and 
  3. communication with the persons served.