2023 Edition

Integrated Care; Health Homes Definition

Purpose

Adults and children who receive integrated care experience improved health care quality, an improved client care experience, and improved clinical and non-clinical outcomes.

Definition

Integrated care is the systematic coordination of behavioral and physical health care in order to improve an individual’s overall health.

Behavioral health providers can offer integrated care by fully integrating primary care into their existing program, establishing written agreements with a primary care provider that is located on-site, or establishing written agreements with a primary care provider that is located in the community.

Examples: One specific model for providing integrated care is the Medicaid health home, which was established by the Patient Protection and Affordable Care Act (ACA) to coordinate health care for adults and children with chronic conditions. The health home is a central point of contact responsible for facilitating access to and systematically coordinating an individual’s behavioral, medical, and oral health care, while making linkages to needed community and social support services.

Health home services that are eligible for federal reimbursement as authorized by the ACA include:
  1. comprehensive care management;
  2. care coordination and health promotion;
  3. comprehensive transitional care, including appropriate follow-up from inpatient to other settings;
  4. individual and family support;
  5. referral to community and social support services, as applicable; and
  6. the use of health information technology (HIT) to link services.

Examples: Chronic conditions include, but are not limited to, substance use disorders, mental health conditions, asthma, diabetes, heart disease, and having a Body Mass Index (BMI) over 25.

Note:Throughout the ICHH standards, the involvement of the person’s family has been emphasized due to the significant impact family engagement can have on resilience and recovery. However, the level of family involvement will vary given the age and expressed wishes of the person and as permitted by law.


Due to the importance of family involvement in achieving positive outcomes for children, all aspects of service delivery should be family-driven when working with this population, accounting for the dynamics of the family as well as the needs of the child.


Note:Please see ICHH Reference List for the research that informed the development of these standards.


Note:For information about changes made in the 2020 Edition, please see the ICHH Crosswalk.

2023 Edition

Integrated Care; Health Homes (ICHH) 1: Person-Centered Logic Model

The organization implements a program logic model that describes how resources and program activities will support the achievement of positive outcomes.

Note: Please see the Logic Model Template for additional guidance on this standard.  

1
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.

Logic models have been implemented for all programs and the organization has identified at least two outcomes for all its programs.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,  
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • Logic models need improvement or clarification; or
  • Logic models are still under development for some of its programs, but are completed for all high-risk programs such as protective services, foster care, residential treatment, etc.; or
  • At least one client outcome has been identified for all of its programs; or
  • All but a few staff have been trained on use of therapeutic interventions and training is scheduled for the rest; or
  • With few exceptions the policy on prohibited interventions is understood by staff, or the written policy needs minor clarification.
3
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
  • Logic models need significant improvement; or
  • Logic models are still under development for a majority of programs; or
  • A logic model has not been developed for one or more high-risk programs; or
  • Outcomes have not been identified for one or more programs; or
  • Several staff have not been trained on the use of therapeutic interventions; or
  • There are gaps in monitoring of therapeutic interventions, as required; or
  • There is no process for identifying risks associated with use of therapeutic interventions; or
  • Policy on prohibited interventions does not include at least one of the required elements.
4
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.,
  • Logic models have not been developed or implemented; or
  • Outcomes have not been identified for any programs; or
  • There is no written policy or procedures for the use of therapeutic interventions; or 
  • Procedures are clearly inadequate or not being used; or
  • Documentation on therapeutic interventions is routinely incomplete and/or missing; or
  • There is evidence that clients have been harmed by inappropriate or unmonitored use of therapeutic interventions.
Self-Study Evidence On-Site Evidence On-Site Activities
  • See program description completed during intake
  • Program logic model that includes a list of outcomes being measured
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
 

ICHH 1.01

A program logic model, or equivalent framework, identifies:
  1. needs the program will address;
  2. available human, financial, organizational, and community resources (i.e. inputs);
  3. program activities intended to bring about desired results;
  4. program outputs (i.e. the size and scope of services delivered); 
  5. desired outcomes (i.e. the changes you expect to see in service recipients); and
  6. expected long-term impact on the organization, community, and/or system.

Examples: Please see the W.K. Kellogg Foundation Logic Model Development Guide and COA’s PQI Tool Kit for more information on developing and using program logic models.

Examples: Information that may be used to inform the development of the program logic model includes, but is not limited to: 
  1. needs assessments and periodic reassessments; and
  2. the best available evidence of service effectiveness.
 

ICHH 1.02

The logic model identifies client outcomes in at least two of the following areas:
  1. change in clinical status;
  2. change in functional status;
  3. health, welfare, and safety;
  4. permanency of life situation; 
  5. quality of life; 
  6. achievement of individual service goals; and 
  7. other outcomes as appropriate to the program or service population.

Interpretation: Outcomes data should be disaggregated to identify patterns of disparity or inequity that can be masked by aggregate data reporting. See PQI 5.02 for more information on disaggregating data to track and monitor identified outcomes. 

Examples: Quality measures for integrated programs serving adults can include, but are not limited to:
  1. body mass index;
  2. screening for clinical depression;
  3. hospital admissions and readmissions;
  4. emergency room visits;
  5. skilled nursing facility admissions;
  6. initiation and engagement of alcohol and other drug use treatment; 
  7. tobacco use;
  8. appointment attendance; and
  9. measures related to chronic medical conditions such as hypertension, diabetes, and asthma. 
Quality measures for integrated programs serving children can include, but are not limited to: 
  1. body mass index;
  2. immunization status;
  3. well-child visits;
  4. school attendance;
  5. placement disruptions in child welfare;  
  6. juvenile justice recidivism; 
  7. residential placements;
  8. hospital admissions and readmissions;
  9. measures related to chronic conditions such as asthma, diabetes, and ADHD; and
  10. other clinical and functional outcomes found on standardized, child-oriented tools such as the Child and Adolescent Needs and Strengths (CANS).
2023 Edition

Integrated Care; Health Homes (ICHH) 2: Personnel

Personnel have the competency and support needed to provide services and meet the needs of persons served.
Interpretation: Competency can be demonstrated through education, training, or experience. Support can be provided through supervision or other learning activities to improve understanding or skill development in specific areas.

1
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.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,  
  • With some exceptions, staff (direct service providers, supervisors, and program managers) possess the required qualifications, including education, experience, training, skills, temperament, etc., but the integrity of the service is not compromised; or
  • Supervisors provide additional support and oversight, as needed, to the few staff without the listed qualifications; or 
  • Most staff who do not meet educational requirements are seeking to obtain them; or 
  • With few exceptions, staff have received required training, including applicable specialized training; or
  • Training curricula are not fully developed or lack depth; or
  • Training documentation is consistently maintained and kept up-to-date with some exceptions; or
  • A substantial number of supervisors meet the requirements of the standard, and the organization provides training and/or consultation to improve competencies when needed; or
  • With few exceptions, caseload sizes are consistently maintained as required by the standards or as required by internal policy when caseload has not been set by a standard; or
  • Workloads are such that staff can effectively accomplish their assigned tasks and provide quality services and are adjusted as necessary; or
  • Specialized services are obtained as required by the standards.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards.  Service quality or program functioning may be compromised; e.g.,
  • A significant number of staff (direct service providers, supervisors, and program managers) do not possess the required qualifications, including education, experience, training, skills, temperament, etc.; and as a result, the integrity of the service may be compromised; or
  • Job descriptions typically do not reflect the requirements of the standards, and/or hiring practices do not document efforts to hire staff with required qualifications when vacancies occur; or 
  • Supervisors do not typically provide additional support and oversight to staff without the listed qualifications; or
  • A significant number of staff have not received required training, including applicable specialized training; or
  • Training documentation is poorly maintained; or
  • A significant number of supervisors do not meet the requirements of the standard, and the organization makes little effort to provide training and/or consultation to improve competencies; or
  • There are numerous instances where caseload sizes exceed the standards' requirements or the requirements of internal policy when a caseload size is not set by the standard; or
  • Workloads are excessive, and the integrity of the service may be compromised; or 
  • Specialized staff are typically not retained as required and/or many do not possess the required qualifications; or
  • Specialized services are infrequently obtained as required by the standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards.
Self-Study Evidence On-Site Evidence On-Site Activities
  • List of program personnel that includes:
    • Title
    • Name
    • Employee, volunteer, or independent contractor
    • Degree or other qualifications
    • Time in current position
  • See organizational chart submitted during application
  • Table of contents of training curricula
  • Procedures or other documentation relevant to continuity of care and case assignment
  • Training curricula
  • Documentation tracking staff completion of required trainings and/or competencies
  • Caseload size requirements set by policy, regulation, or contract, when applicable
  • Documentation of current caseload size per worker
  • Interviews may include:
    1. Program director
    2. Relevant personnel
  • Review personnel files
 

ICHH 2.01

Personnel are trained on, or demonstrate competency in:
  1. coordinating and providing access to needed services; 
  2. facilitating transition planning and coordination; 
  3. applicable evidence-based interventions;
  4. physical health issues commonly associated with mental health or substance use conditions; 
  5. health conditions and treatment responses particular to the service population;
  6. chronic disease management, including promoting self-management; 
  7. developing a person- or family-centered care plan; 
  8. understanding the roles played by different child-serving systems, as applicable; and 
  9. using health information technology to link services and facilitate collaboration among providers, the person, and his or her family.
 

ICHH 2.02

The organization maintains service continuity for persons served by:
  1. assigning the care planning team at intake or early in the contact; and
  2. avoiding the arbitrary or indiscriminate reassignment of direct service personnel.
 

ICHH 2.03

Employee workloads support the achievement of client outcomes and are regularly reviewed.

Examples: Factors that may be considered when determining employee workloads include, but are not limited to: 
  1. the qualifications, competencies, and experience of the worker including the level of supervision needed;
  2. services provided by other professionals or team members;
  3. the work and time required to accomplish assigned tasks and job responsibilities; and
  4. service volume, accounting for assessed level of needs of persons served.
2023 Edition

Integrated Care; Health Homes (ICHH) 3: Administrative Practices

The organization's administrative practices support effective health care integration.

1
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.
2
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.
3
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. 
4
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 Evidence On-Site Evidence On-Site Activities
  • Procedures that outline appropriate terminology and concepts to use for documentation
  • Copies of informational materials provided to clients and other stakeholders
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records
  • Observe health information technologies
 

ICHH 3.01

Documentation techniques utilize common terms and concepts to facilitate clear and effective communication between primary and behavioral health care providers.
 
Fundamental Practice

ICHH 3.02

The organization clearly defines for its stakeholders: 
  1. the scope of services offered directly by the organization; 
  2. how information will be shared both internally and externally among collaborating providers; and 
  3. the nature of the relationship that exists between providers when direct services are provided through contract or other agreement between separate legal entities.
 

ICHH 3.03

The organization uses health information technologies to:
  1. link services including shared access to the person's health information; 
  2. organize, track, and analyze critical program information including referrals and needed follow-up; and
  3. satisfy applicable reporting requirements.
2023 Edition

Integrated Care; Health Homes (ICHH) 4: Assessment

The person and his or her family participate in a comprehensive, strengths-based, individualized assessment to identify service needs and goals.

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VIEW THE STANDARDS

1
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.
2
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
  • In a few rare instances, urgent needs were not prioritized; or
  • For the most part, established timeframes are met; or
  • Culturally responsive assessments are 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.
3
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
  • Urgent needs are often not prioritized; or 
  • Services are frequently not initiated in a timely manner; or
  • Applicants are not receiving referrals, as appropriate; or 
  • Assessment and reassessment timeframes are often missed; or
  • Assessment are sometimes not sufficiently individualized; 
  • Culturally responsive assessments are not the norm, and this is not being addressed in supervision or training; or
  • Several client records are missing important information; or
  • Client participation is inconsistent; or
  • Intake or assessment is done by another organization or referral source and no documentation and/or summary of required information is present in case record. 
4
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.,
  • There are no written procedures, or procedures are clearly inadequate or not being used; or
  • Documentation is routinely incomplete and/or missing.  
Self-Study Evidence On-Site Evidence On-Site Activities
  • Assessment procedures
  • Copy of assessment tool(s)
  • Procedures for referring individuals to specialized screenings, assessments, or tests when needed
  • Community resource and referral list
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records
 

ICHH 4.01

Persons served participate in an individualized, culturally and linguistically responsive assessment that is completed within established timeframes.

Interpretation: The Assessment Matrix - Private, Public, Canadian, Network determines which level of assessment is required for COA’s Service Sections. The assessment elements of the Matrix can be tailored according to the needs of specific individuals or service design.

 

ICHH 4.02

Assessments are conducted using a standardized assessment tool to identify: 
  1. basic needs including food, clothing and shelter;
  2. the person's behavioral health, physical health, and community and social support service needs and goals;
  3. history of trauma;
  4. relevant systems involvement;
  5. individual and family strengths, risks, and protective factors;
  6. natural supports and helping networks; and
  7. the impact of the individual’s health care needs on the family unit.

Examples: For organizations serving children, systems involvement can include education, child welfare, and juvenile justice.
 

ICHH 4.03

The assessment incorporates applicable information from a variety of sources, which include, but are not limited to: 
  1. the person; 
  2. the person’s family;
  3. medical and/or clinical case records;  
  4. the results of screening tools; 
  5. relevant content from assessments completed by partnering or referring providers;
  6. other providers; and 
  7. members of the care planning team.

Examples: Organizations can review assessments completed by partnering or referring providers to identify, for example:
  1. gaps in information;
  2. out-of-date information; and 
  3. information that can be used to minimize duplication of effort.
 
Fundamental Practice

ICHH 4.04

Assessment procedures include mechanisms to identify and respond to individuals or families in crisis including:
  1. giving priority to urgent needs and emergency situations;
  2. expedited care planning; 
  3. connecting the individual to more intensive services as needed; 
  4. facilitating the development of a safety and/or crisis plan; and
  5. contacting emergency responders as appropriate.
 

ICHH 4.05

The organization promptly provides or makes arrangements for specialized screenings, assessments, or tests as needed based on information collected during initial and ongoing assessments.
2023 Edition

Integrated Care; Health Homes (ICHH) 5: Care Planning and Monitoring

The person and his or her family participate in the development and ongoing monitoring of a care plan that is the basis for delivery of appropriate services and support.

1
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.
2
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
  • In a few instances, client or staff signatures are missing and/or not dated; or
  • With few exceptions, staff work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc.; or
  • Active client participation occurs to a considerable extent.
3
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
  • In several instances, client or staff signatures are missing and/or not dated; or
  • Quarterly reviews are not being done consistently; or
  • Level of care for some clients is clearly inappropriate; or
  • Service planning is often done without full client participation; or
  • Appropriate family involvement is not documented; or  
  • Documentation is routinely incomplete and/or missing; or
  • Individual staff members work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc., but this is the exception.
4
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 Evidence On-Site Evidence On-Site Activities
  • Service planning and monitoring procedures
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records
 

ICHH 5.01

An assessment-based care plan is developed in a timely manner with the full participation of the individual and his or her family and includes: 
  1. the person's behavioral health, physical health, and community and social support service needs and goals, including basic needs when applicable; 
  2. steps for working toward achievement of desired goals including timeframes where appropriate;
  3. services and supports to be provided, and by whom; 
  4. possibilities for maintaining and strengthening family relationships and other informal social networks;
  5. agreed upon timelines for conducting regular case reviews; and 
  6. documentation of the individual’s or family’s involvement in care planning.
 

ICHH 5.02

The care coordinator and the care planning team actively review the case according to established timelines to assess:
  1. continued accuracy of the assessment;
  2. care plan implementation;
  3. the person’s continued engagement in his or her treatment;
  4. the person’s progress toward achieving goals and desired outcomes; and
  5. the continuing appropriateness of agreed upon service goals.
Interpretation: Timeframes for the review should be defined by the person and the care coordinator and take into consideration the issues and needs of the person and the frequency and intensity of services provided. Traumatic events or other significant life changes such as changes in housing, disclosure of abuse, hospitalization, or contact with the criminal justice system should trigger an immediate review of the case.
 

ICHH 5.03

The care coordinator, the individual, and his or her family:
  1. regularly review progress toward achievement of agreed upon goals; and  
  2. sign revisions to service goals and plans.
2023 Edition

Integrated Care; Health Homes (ICHH) 6: Care Coordination

All aspects of the person’s treatment are coordinated and monitored in accordance with the care plan to ensure access to and coordination of needed behavioral health care, physical health care, and community and social support services.

Note: Care coordination in this context includes coordination of any services provided directly by the organization as well as those provided through linkages to community providers.

1
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.
2
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.
3
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. 
4
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 Evidence On-Site Evidence On-Site Activities
  • Care coordination procedures
  • Care transition procedures
  • Procedures for conducting or tracking medication reconciliation and adherence
  • Copy of agreement with and/or job description and resume for each member of the care planning team, including a physician and psychiatrist for consultation
  • Copies of agreements with community providers, as applicable
  • Community resource and referral list
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records
 
Fundamental Practice

ICHH 6.01

The care planning team includes at a minimum: 
  1. a designated care coordinator with qualifications appropriate to the needs of the identified service population; 
  2. a primary care professional such as a physician’s assistant or nurse practitioner with access to a physician for needed consultation;  
  3. a behavioral health professional such as a social worker, psychologist, or other licensed clinician with access to a psychiatrist for needed consultation; and
  4. other providers and supports based on the needs of the individual.

Examples: The qualifications of the designated care coordinator will vary given the needs of the identified service population. For adults with serious and persistent mental health conditions, for example, a medical professional such as a nurse practitioner may be preferred given the high prevalence of comorbid, chronic, physical health conditions present in this population. For children, however, where chronic medical conditions are far less common, the coordination of behavioral health care and linkages to community and social support services might best be carried out by a behavioral health practitioner with experience working with children and families.

Examples: Organizations can leverage alternative service delivery methods such as telehealth and telemental health when regional shortages of certain professional groups, such as psychiatrists, make in-person consultation impractical.

Examples: Supports that may also be included on the care planning team can include, but are not limited to, peer mentors and natural supports as appropriate to the needs of the individual.
 

ICHH 6.02

The roles and responsibilities of each team member are clearly defined.
 

ICHH 6.03

The organization facilitates access to the full array of community and social support, behavioral health care, and physical health care services by:
  1. establishing partnerships and coordination procedures with direct service providers in the community; 
  2. establishing communication procedures with persons served and across disciplines, both internally and externally;
  3. maintaining a comprehensive, up-to-date referral list;
  4. removing barriers to the initiation of needed services including procedures for providing a warm hand off when needed services are provided directly by the program or on-site through a partnering provider; and
  5. assisting the person with system navigation.
Interpretation: The array of community and social support services and behavioral and physical health care services that should be made available to persons served include:
  1. preventative and health promotion services;
  2. mental health and substance use services;
  3. comprehensive care management, care coordination, and transitional care;
  4. chronic disease management, including self-management;
  5. community, social support, and recovery services; 
  6. peer support services; and
  7. long-term care supports and services.
 

ICHH 6.04

Individuals are assisted in making appointments for needed or requested services, and the care coordinator follows up to: 
  1. ensure the service was received; 
  2. identify any needed follow-up; and 
  3. make needed changes to the care plan in partnership with the person and his or her family.
 

ICHH 6.05

The care coordinator supports smooth transitions between care settings by: 
  1. coordinating information sharing and service provision with providers and the person; 
  2. developing, or supporting the development of, a comprehensive discharge or transition plan with steps for follow-up; and
  3. facilitating face-to-face interactions between providers, whenever possible.

Examples: Supported transitions can include, but are not limited to, transitioning from inpatient hospitalization, residential treatment, therapeutic group care, the juvenile justice system, foster care, and from pediatric to adult settings.
 
Fundamental Practice

ICHH 6.06

The organization:
  1. conducts medication reconciliation and adherence; or
  2. tracks that it is being done by another provider as part of their care coordination activities.
 

ICHH 6.07

Care coordination activities are documented in the case record, including: 
  1. linkages to community providers as well as completed follow-up; 
  2. communication with partnering providers both internally and externally; and 
  3. communication with the person.

Examples: Care coordination activities that are documented in the case record can also include sharing the results of screenings and diagnostic and laboratory testing.
2023 Edition

Integrated Care; Health Homes (ICHH) 7: Health Promotion

The organization ensures that individuals and their families have access to health information and resources that enable them to manage their chronic conditions and improve their overall health.

1
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.
2
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.
3
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. 
4
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 Evidence On-Site Evidence On-Site Activities
No Self-Study Evidence
  • Aggregate reports and analysis from health data tracking
  • Evidence of improvements made to health promotion activities based on data collection activities
  • Health promotion educational materials, training curricula, and other information made available to clients
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Observe system for tracking health data
  • Review case records
 

ICHH 7.01

Health data for persons served is collected, aggregated, and analyzed to inform individual and organization-wide health promotion activities.

Examples: Patient registries can be one effective method for collecting, organizing, and analyzing health data.
 

ICHH 7.02

When choosing or designing health promotion activities, the organization considers:
  1. individual characteristics and abilities; and
  2. evidence-based practices and concepts.
 

ICHH 7.03

The organization offers individuals and their families health education on topics relevant to their needs that will empower them to manage their chronic conditions and promote wellness.

Examples: Education topics can include, but are not limited to, smoking cessation, nutrition, physical fitness, obesity education, the connection between mental and physical health, chronic disease management, medication use, and resilience and recovery.
 

ICHH 7.04

Services promote self-advocacy and independence by: 
  1. connecting individuals and families to informal support systems in their community; and 
  2. educating individuals and families on where to access needed services.
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