Behavioral Health - Key Activity 14


This key activity involves the following elements of person-centered population-based care: proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.


This activity will help you provide care that is person-centered and coordinated across all internal and external providers involved with the patient.

Care coordination involves deliberately organizing patient care activities and sharing information among all participants concerned with a patient’s care to achieve safer processes and more effective outcomes.

Care coordination is an integral part of providing high quality population-based care in an ambulatory care clinic. In your practice, care coordination happens daily as part of standard work and includes activities, such as assisting patients with referrals, managing patient messages, and receiving incoming information from outside care partners, including pharmacies, specialists, hospitals and community partners (e.g., schools, employers, community-based organizations). Behavioral health clinicians and staff should be an integral part of care coordination activities, as their skills and expertise are an asset in providing comprehensive and effective support to patients with complex medical needs.

Managing care across multiple settings is often a source of frustration and dissatisfaction for both patients and providers. Lack of coordinated care can result in both duplication of services and a lack of completion of needed services. When care is not coordinated, decisions can be made without a complete picture of the patient’s needs and goals. Knowing roles and responsibilities and working as part of a multidisciplinary team are foundational elements of providing integrated behavioral health and are complementary to the work of care coordination.

Practices that have effective care coordination processes often employ closed loop referrals as a best practice. In a closed loop referral, a referring provider can track the status of the referral (e.g., completed or pending) as well as the outcome of the referral, including whether additional follow up is needed. When closed loop referrals are implemented, both provider and patient satisfaction are enhanced.

There are four fundamental concepts when thinking about care coordination activities within your practice:

  • Accountability: A key to successful care coordination is accountability. Clinics and systems that excel at care coordination take ownership and assume responsibility for care coordination activities. Examples of care coordination processes include development of infrastructure for care coordination, identification of staff responsibilities, and relationship building with referral partners. Together, these actions create the ability to support referrals and transitions and track them to completion.
  • Patient support: Referrals and transitions often raise questions for patients and families and can be a source of anxiety. Not only do the logistics of a referral or transition create questions, but also patients and their families can experience anxiety regarding the outcome or purpose of a referral or transition. When a practice can dedicate staff time to addressing the needs of patients and families, referrals and transitions are most likely to accomplish intended goals.
  • Relationships and supports: Referrals and transitions work best when all parties – patients, primary care providers, and consultants – agree on the purpose and importance of the referral and the roles that each will play in providing care.
  • Connectivity: Building relationships and agreements among providers, including community agencies, lead to shared expectations for communication and care. Connectivity includes developing referral relationships, accepting accountability, and creating data flow.

In order to conceptualize how practices can coordinate with community-based agencies (housing, food, income support), hospitals and ERs, and specialists, refer to the visual depiction of the care coordination model by the Center for Accelerating Care Transformation (ACT Center).

Care coordination can benefit all patients in your practice and care coordination processes, such as closed loop referrals, can be applicable to many practice activities (see example considerations in Figure 12). Common areas where care coordination can be enhanced include specialty referrals and referral to social supports, such as transportation and housing needs. Care coordination activities can also identify patients who need a higher level of support through a care management program (see Key Activity 20: Improve Care of People with More Severely Impacting Conditions). Care management differs from care coordination in that a patient consents to and works directly with a care manager to create a care plan that is shared with an extended care team. While a practice can decide whether it has the resources to provide higher level care management services, care coordination is a foundational activity of effective population health management.

Care coordination for Medi-Cal patients

Patients with Medi-Cal have access to many resources that can support improved health outcomes and social needs. These Medi-Cal resources can be another opportunity to create care coordination processes in your practice; see Figure 11 for a partial list of Medi-Cal programs that involve care coordination. As of 2023, both doula care and community health worker (CHW) services are benefits of the Medi-Cal program. Doulas provide evidence-based culturally competent (racial, ethnic, linguistic) services aimed at preventing perinatal complications and improving health outcomes for birthing. The services of CHWs (also known as Promotores/Community Health Resources) can be highly effective in helping to connect patients to resources and educational materials that are community-based and aligned with a patient’s values, language and cultural needs to further health equity. The California Health Care Foundation offers an overview of the CHW program, including potential hurdles.

Medi-Cal patients with high medical, behavioral health, and/or social needs may be eligible for Enhanced Care Management and Community Supports (see Key Activity 20: Improve Care of People with More Severely Impacting Conditions for more information on these programs).

There are also a number of Medi-Cal programs that provide services and support to Medi-Cal patients who qualify. Care coordination between the practice and these programs can result in more integrated care for eligible patients. Some examples include:

  • California Children’s Services (CCS): Care coordination and support for eligible children with high levels of medical needs.
  • Long-term services and supports (LTSS): These are available to support individuals in the community and include skilled nursing facility services, personal care services, self-directed personal assistance services, in-home supportive services, and home- and community-based services.


  • Enhanced Care Management
  • Community Supports
  • Community Health Workers
  • Doula
  • Long term services and supports (LTSS)
  • California Children’s Services (CCS)

Effective care coordination helps your practice to better meet the broad range of patients' needs and preferences. It helps ensure that each patient's needs and preferences are known and communicated at the right time to the right people and that this information is used to guide the delivery of safe, appropriate and effective care.

Key outcomes of care coordination:

  • Greater patient participation and satisfaction.
  • Closed gaps and addressed inequalities that exist in access to care.
  • Improved quality outcomes and the potential to leverage quality financial incentives.
  • Decreased staff burnout and duplication of services (e.g., “Let the system do the work”).

Effective care coordination helps to reduce health inequities among different populations by better identifying and then working to address a broad range of patients’ needs. By identifying outside clinical supports (e.g., hospital care, specialist care) and social supports (e.g., housing assistance, transportation, food insecurity, etc.) and creating pathways for coordination, the practice promotes equity by facilitating access to these services for all patients who need them.

As part of a care coordination strategy, practices should consider the growing number of aggregator organizations (see resources section below) that partner with community-based programs and resources centered around addressing social needs, such as housing, food and community. Many of these community-based programs are tailored for specific demographic groups and can support patients in meeting their needs in a culturally competent way.

Technology can be used to streamline and enhance care coordination. Care coordination technology tools can support care coordination activities, such as registry, clinical decision support, care gap reporting, and patient inreach and outreach engagement technology. See additional considerations under “Address Connectivity” below.

Practices can use a care coordination self-assessment tool, such as those referenced in the action steps below, to determine if additional technology support is needed.

Registry and care gap reporting
Practices can use an analytics platform to identify patients and group patients who have similar needs together. Your practice can then tailor interventions to meet the needs of a population. For example, a practice can use data to identify those people who have not had a visit in the past year or those who are due for colon cancer screening. Data can come directly from the medical records or from claims data that is submitted to the payor.

Care coordination software: Clinical decision support
Many EHRs have care coordination modules, which can be used to develop assessments and care plans. Alternatively, care coordination modules can be add-ons to EHRs. Care coordination software can support assessment, referral and coordination pathways (e.g., clinical decision-making support). Using a care coordination software module, a practice can develop an assessment with questions regarding a patient’s social health needs. If answers are positive, the software can be configured to provide referral pathways and prompt care coordination activities. For example, if a patient answers “Yes” to questions on food insecurity, the assessment can prompt referral to local resources, such as food banks, meal programs and nutritional supports. The system can also prompt the staff to reassess progress at the next visit.

For more information, see Appendix D: Guidance on Technological Interventions.

Action steps and roles

The action steps and roles outlined below provide a framework for assessing current state, developing a strategy, implementing care coordination, and monitoring and learning as you progress.

1. Establish a call to action for care coordination.

Suggested team member(s) responsible: Behavioral health lead.
To achieve effective care coordination, staff need consider your practice needs to see itself as a hub or center for coordination of patient care.

  • While all providers within a patient’s support network need to collaborate, your practice should view itself as accountable for care coordination for empaneled patients and patients who have been assigned to your practice by their managed care plan.
  • Identify a care coordination team who will be responsible for leading the evaluation, assessment and implementation of care coordination activities.
  • Share with the care coordination team why care coordination is important.
  • Some areas to address:
    • What is care coordination?
    • Why does care coordination benefit staff and patients?
    • Review the proposed framework (e.g., assess, develop strategy, implement, monitor) to develop the care coordination activity.
    • Identify and share some initial projects directed at enhancing care coordination.
    • Invite and engage staff and patients to provide input on how they think care coordination can be enhanced.
    • Discuss how best to incorporate feedback from patients.
  • Use feedback from this activity and incorporate it into the assessment.


2. Assess your practice’s current state of care coordination activities.

Suggested team member(s) responsible: IBH implementation team, panel manager, QI lead, BH lead.

Analyze existing systems and processes:

  • Review existing care coordination protocols, technologies and resources utilized by health centers
  • Explore how technology is currently being used to support care coordination. Then, explore how technology could be harnessed to streamline care coordination, improve data sharing, and/or enhance communication among providers.
  • Review existing formal and informal linkage agreements.
  • Conduct an analysis to determine patient needs not yet fully addressed by existing agreements.
  • Assess data on patient outcomes, satisfaction, and any existing quality improvement initiatives.
  • The following resources can help your practice assess its current state:


3. Develop and implement a care coordination improvement strategy.

Suggested team member(s) responsible: Panel manager and quality improvement lead.

Develop your high-level care coordination improvement strategy.

  • The high-level strategy is based on the results and insights from your care coordination assessment and your practice’s capacity or bandwidth.
  • Establish clear objectives.
  • Define specific, measurable, achievable, relevant, time-bound, inclusive and equitable (SMARTIE) goals for enhancing care coordination.
  • Ensure that these goals align with the overall mission and values of your practice.
  • Prioritize areas for improvement. Identify a limited set of key focus areas, such as communication protocols, technology integration, staff training, or patient engagement strategies, based on the assessment’s findings and your practice’s bandwidth.

Identify resources and infrastructure.

  • As part of the strategy’s implementation, identify the resources and infrastructure needed to support care coordination at your practice.
  • In Figure 12, we have included some considerations by resource as you develop your care coordination implementation plan. Note: some of the resources may not apply to your practice.






Dedicated time for the development, training and implementation of the CC activity.
Defining ongoing staffing needs.

Internal tools

Electronic health record modifications. Data needs and technology needed to implement the CC activity.


Development of workflows, training materials, communication plan, and job descriptions. Identification of what CC activities will be the responsibility of the practice staff.

Funding and finance

Explore benefits, such as Enhanced Care Management or community health workers, as well as financial resources that may be available through external partners, such as health plans or hospitals.

Clinical decision-making support

Medical staff, behavioral health, and patients as subject matter experts (SMEs).

External support and data

Information and resources required from the entity with which the clinic is coordinating (e.g., hospital, specialist, social health clinician). Data exchange requirements including the new California Data Exchange Framework (DxF) on privacy.

Develop staffing for care coordination.

  • Determine who at your practice will be involved in care coordination.
  • The PHMI Care Teams and Workforce Guide provides an overview of care coordination using a care coordinator or referral manager.
  • Based on the population of focus and the intervention, develop staffing requirements and any job description changes to embed care coordination into your practice.
  • The responsibilities of a person or people fulfilling care coordination roles should include, at a minimum:
    • Manage the referral process.
    • Assist patients with transitions, such as those to and from hospitals and other institutions.
    • Help patients resolve logistical, financial and/or other barriers to a successful referral.
    • Link patients with community resources.
    • Link patients with peer support services.
    • Follow up with patients within a few days of an emergency room visit, hospital discharge, or discharge from a treatment facility.
    • Ensure the safe transfer of patient data.
    • Track progress (e.g., referral milestones).
    • Assist patients who are having difficulties.
    • Schedule follow-up and specialty appointments for and with patients.
  • Formalize this role through a job description or position description.
  • Provide regular training and support to the care coordinator, referral coordinator or similar.

Develop or refine your policies and procedures for care coordination. At a minimum, they should include all of the following:
Identifying patients who are eligible for care coordination.

  • Defining the activities that are associated with care coordination (e.g., inreach, engagement, assessment, desired outcome).
  • Managing the referral process.
  • Ensuring the safe transfer of patient data.
  • Tracking progress through closed loop referral (see referral milestones above).
  • Identifying patients who might benefit from higher levels of care coordination, such as care management interventions. More about care management is discussed in Key Activity 20: Improve Care of People with More Severely Impacting Conditions.

Develop or refine your referral protocols.

  • Develop clear guidelines for when and how to make clinical referrals.
  • Include criteria for urgent vs. nonurgent referrals.
  • For each provider your practice will be referring to:
    • Identify the information, format and process the provider requires to receive a referral.
    • Share the information you will need back from the provider when the referral has been successfully made and/or once the service or support has been provided to ensure continuity of care and nonduplication of services.
    • Formalizing this through a written agreement or compact is a good way to ensure expectations on both sides of a referral are understood.
  • In working with community agencies or organizations that provide social support, the specific information that can and should be shared will depend on the service. It is important to have a mutual understanding about that information, using a written agreement, where possible. At minimum, if the referral did not include a warm handoff, there should be an expectation that the practice hears back from the organization to let them know whether the patient followed up on the referral. Sample primary care checklist suggestions for assessing referral process.

Address connectivity. For any providers that you are exchanging patient data with, your practice should develop formal agreements and processes. Here are some considerations to facilitate information sharing among providers involved in an individual’s care:

  • Integrate documentation platforms, where possible, and standardize how documentation is included in patients’ records.
  • Ensure that behavioral health records are integrated into the overall EHR system to the extent permitted by law.
  • Enable providers to access comprehensive patient information.
  • Identify and assess participation in health information exchanges and/or social health informatione.
  • Exchange systems, where feasible, to facilitate seamless sharing of patient information. These exist in some communities and will develop over time. This explainer series from the California Health Care Foundation describes the new statewide health information exchange coming into effect in 2024.
  • Understand when patient consent is required to ensure compliance with privacy regulations, such as HIPAA. Include consent processes in the referral protocols.
  • Set expectations about the information that should be shared and develop processes for facilitating that exchange. As data that is used in a clinical setting will likely be different than information that is shared by community agencies or social support networks, it is imperative to have clear parameters around what types of information can be exchanged between your practice and your partners.

Provide care coordination to patients.

The following resources can help your practice develop your care coordination improvement strategy:


4. Continuous quality improvement of care coordination.

Suggested team member(s) responsible: QI lead, IBH implementation team.

  • Develop both formal and informal mechanisms to obtain feedback from providers, staff and patients on the effectiveness of your practice’s care coordination efforts and to identify areas for improvement.
  • Establish key performance indicators related to care coordination. Consider using AHRQ’s Care Coordination Quality Measures for Primary Care (CCQM-PC). Your performance indicators will vary based upon your improvement strategy and the needs of patients, but may include metrics, such as:
    • Number of assigned patients engaged in care.
    • Number of individuals with hypertension whose BP is controlled.
    • Percent of closed loop referrals by referral entity. Monitor and analyze metrics to gauge the effectiveness of your internal systems and how well each referral partner is promoting coordination and collaboration.
    • Number of patients with a high rate of emergency room visitation who have been introduced to the practice’s behavioral health staff.
  • Continue to build relationships with providers and community support agencies that are available to provide services to the practice’s patients.
  • Consider developing and using a care coordination variance report. Here is a sample patient care coordination variance report.

Implementation tips

  • An interoperable referral management system can help practices streamline the intake process, communicate with other providers and social service agencies, track the status and outcomes of referrals, and ensure that patients receive the appropriate level of care and support.
  • Leverage community health information exchanges (HIE) to gain access to admission, discharge, and transfer information. Absent being able to access an HIE, establish relationships with your local hospitals to be able to gain daily notification of your patients being discharged.