Care Standards Library

community coordination

Patient/Client Assignment

Begin with triage by a case manager (or similar) who will determine appropriate interventions and team members.

community coordination

Patient/Client Enrollment

An initial patient/client meeting is followed by completion and signature of required forms, such as Release of Information and enrollment forms.

community coordination

Patient/Client Intake

The patient/client care team is assembled in a shared electronic workspace, and various assessments of the patient/client may be completed.

community coordination

Intervention Workflow

Patient/client goals are placed at the center of the shared care plan. Assessment and screening data helps to identify additional next steps. Referrals are processed.

community coordination

Care Team Follow-Up

Patient/client shared care plan is updated as tasks are completed and milestones are achieved. Re-assessments and recurring tasks occur as needed, with reminders scheduled according to intervention frequency.

community coordination

Patient/Client Disenrollment

A disenrollment assessment is completed, and close-out paperwork and required documentation is finalized.

referral management

Referral to Care Supports & Services

Help with adoption services, foster care, animal welfare, daytime care, end-of-life care, residential care, navigating the system, or engaging a support network.

referral management

Referral to Education Services

Help finding school, paying for school, attaining more education, enrolling in preschool, or finding exam and training opportunities.

referral management

Referral to Emergency & Crisis Services

Can include help with emergency food, shelter, or financial assistance; as well as help escaping violence, finding missing persons, engaging psychiatric emergency services, or disaster response.

referral management

Referral to Employment Services & Supports

Help finding work, paying for work-related expenses, accessing skills training, gaining supported employment, or advocacy related to workplace rights.

referral management

Referral to Essential Goods & Supplies

Help procuring baby supplies, clothing, home goods, medical supplies, or toys and gifts.

referral management

Referral to Financial Assistance

Help accessing financial assistance, government benefits, financial education, insurance, or tax preparation services.

referral management

Referral to Food & Nutrition Support

Help accessing community garden offerings, emergency food, food delivery, food pantry assistance, free meals, nutritional services, or help paying for food.

referral management

Referral to Health Services

Help accessing addiction and recovery services, dental care, end-of-life care, health education, and medical or mental health care, and help paying for healthcare.

referral management

Referral to Housing Services

Help accessing emergency shelter, finding housing, paying for housing, or navigating housing services.

referral management

Referral to Legal Aid

Help securing legal representation, advocacy services, legal aid, mediation, notary services, as well as translation and interpretation.

referral management

Referral to Transportation Support

Help paying for transit, accessing non-emergency medical transportation, or other needed transportation help.

referral management

Referral to Veterans Services

Help accessing veterans services, within the VA/VHA, or local support organizations and networks, or state and national advocacy entities.

referral management

Reject a Referral

When an organization rejects a referral, the appropriate persons are notified and can begin the process of securing alternate services.

referral management

Redirect a Referral

When an organization cannot accept a referral but knows of another organization that can, they can redirect the referral to that organization.

referral management

Close the Loop on a Referral

When an organization can confirm that a patient/client's need has been met, they can close the loop by notifying the referring/sending organization that this task is complete.

reporting & analytics

Pull/Schedule Data Extracts

Allows analysts and program managers to pull all or specific data on-demand, as well as schedule pre-defined data extracts for any recurring cadence or future date.

reporting & analytics

Review Patient/Client Assignments

Allows you to answer questions such as how many active patients/clients are currently assigned to whom, including those not assigned.

reporting & analytics

Review Task Assignments

Allows you to answer questions such as how many tasks and which tasks are currently assigned to whom.

reporting & analytics

Review Task Status

Allows you to answer questions such as how many outstanding, overdue, or incomplete tasks are assigned to whom, right now.

reporting & analytics

Review Activity by Employee

Allows you to answer questions such as how many team members have been active, how many times have they logged in, and how many patient/client plans have been touched.

reporting & analytics

Review Activity by Organization

Allows you to answer questions such as which organizations in your network have been active, how many times have they logged in, and how many patient/client plans have been touched.

reporting & analytics

Review Enrollment Data

Allows you to query data related to your patient/client population, such as age, insurance, languages, ethnicity, location, and more.

reporting & analytics

Review Care Process Progress

Allows you to answer questions such as how many patients/clients have achieved or have not yet achieved individual goals, intervention milestones or program enrollment stages.

reporting & analytics

Review Care Process Velocity

Allows you to answer questions such as how fast are your patients/clients achieving individual goals, intervention milestones or program stages.

reporting & analytics

Review Billable Events

Allows you to answer questions such as how many billable events were completed by your team, individual employees, or related to certain individual patients/clients or cohorts.