Best Practices for Continuity of Care During and After Care Coordination

Rula leaves the decision of whether or not to resume care with your client after a higher level of care (HLOC) referral up to you as their clinician. In some cases, this means you'll temporarily suspend seeing the client while they engage in a higher level of care support, such as PHP and IOP. In other cases, you should absolutely continue treating the client while they engage in an adjunct service, such as medication management or group therapy. 


NOTE: Best practice is to continue seeing your client until you’ve confirmed they’re actively being treated by another provider and are engaged in the appropriate level of care. Failure to do so can lead to risk for both you and the client. 


Discharge Planning

Discharge planning from any intensive outpatient or partial hospitalization program is a mandatory procedure as per the Mental Healthcare Act of 2017. It can be a client-friendly and highly practical approach to guide them and improve their quality of life and mental health in the community. Proper discharge planning can improve the outcome and prognosis of individuals diagnosed with behavioral health needs.

Continuing Therapy

Often, it’s best practice to ensure clients have step-down care once they have completed a higher level of care treatment. The majority of aftercare plans include a continuation of individual therapy services. Once a client completes any higher level of care program, they typically have the option of continuing with the individual therapist and/or psychiatric provider they worked with while in outpatient treatment. 

While their most recent outpatient therapist may already have insight into areas that require ongoing attention and personal history, the decision to continue with their referring/previous therapist is dependent on a number of factors, including if their most recent therapist specializes in their current needs. 


NOTE: Care Coordinators can rematch clients in the event their most recent provider does not specialize in their current needs. 


Documenting Client Outcomes

Care coordinators will enter a blank note documenting the outcome of any submitted request for an adjunct or higher level of care request in the client’s chart. 

Best practices for providers to ensure clinical recommendations are being/have been addressed and your client has responded to outreach from Care Coordination:

  • Be sure to advise your client that Care Coordinators will be reaching out to them regarding your recommendation
  • Make sure you’re documenting the conversation you’re having with your client regarding your recommendation for adjunct or HLOC services within their progress notes
  • If/when referring to IOP or PHP: 
    • Make sure you’re documenting any potential planning once the individual is discharged/completes the program
    • When terminating care due to HLOC needs, consider potential risks associated with your client being discharged without care. If this is a factor for you, there is always the potential for them to be rematched with another provider who specializes in their needs.
    • Discuss and document reasons why you might be ending care after their completion so your client is aware you’ll no longer be their provider once the program is completed.
      • Consider meeting with your client until they have scheduled their first appointment with a new provider. As their treating clinician, you can decide this at your discretion.
  • If you’re continuing care with your client, make sure to regularly assess their symptoms and/or mood for any potential risks. For more information about utilizing measurement-informed care (MIC) in your everyday practice, please reference Rula’s help center articles HERE.

Communication from Care Coordination

The care coordination team may reach out to you throughout the referral process for the following reasons. Therefore, we ask that you maintain engagement until the referral is complete:

  • Discuss your recommendation for further clarification of your request.
  • Inform you of any limitations in locating your specific request and, therefore, seek your support in recommending alternative options. 

The care coordination team will communicate with you and your client via email and/or phone call. Once the referral is processed and outreach efforts are complete, the care coordinator will leave a care coordination note and/or a blank note in the client’s chart that includes:

  • Details of all actions taken.
  • The overall outcome of the submitted request.

Please check the client’s chart and your email to be apprised of all communication regarding your HLOC request.

Kaiser SoCA Specific Clients

All HLOC referrals are facilitated by the client's designated Kaiser liaison, and the care coordination team is not provided with a timeline for completing the referral or when the client can expect Kaiser outreach. 

Kaiser will conduct an internal assessment to determine if the client meets medical necessity for the recommended level of care. Kaiser will conduct an internal assessment to determine if the client meets medical necessity for the recommended level of care. It is possible that the referral will not be processed for the following reasons:

  • Client is deemed inappropriate for the recommended level of care, and Kaiser will provide the reason(s) for its determination.
  • Client declines treatment.
  • Client does not respond to Kaiser’s outreach attempts. 
NOTE: Kaiser may have questions for the treating therapist to aid in processing the referral. The care coordinator will relay all questions and responses between you and Kaiser. 


For Additional Support

For additional support/consultation with a member of the Clinical Quality team, HERE is the link to the calendar where you can see when they are holding Case Consultations, as well as the Zoom link to join. 

You can also request a private consultation with one of our Clinical Quality Specialists by completing this HERE.

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