Procedure - Care Coordination and Continuity of Care

Responsible Party

Action Required


  1. Maintains, distributes, and shares a Behavioral Health Service Provider Directory, which includes information about providers within the plan, contact information, languages served, alternatives and other cultural options, and the populations served, to all providers and beneficiaries.

  2. Post Provider Directory on the BHSD’s website.

  3. Maintains and provides oversight to contracted and designated providers to ensure they meet the care coordination and continuity of care requirements.

  4. Ensures beneficiaries receive information on how to contact the person or entity formally designated as primarily responsible for coordinating their services.

  5. Develops and implements a transition of care policy that is consistent with Federal and State requirements.

Call Center​

  1. Reviews electronic health record information to determine if the beneficiary has a person or entity formally designated as primarily responsible for care coordination (provider).

  2. Conducts initial screening to identify the beneficiary’s needs. Staff will make subsequent attempts to conduct initial screening if the initial attempt is unsuccessful.

  3. Notifies the assigned provider of beneficiary short or long-term hospitalization or institutional placement.

  4. Refers beneficiaries to a provider if they do not have one assigned.

Assigned Providers​

  1. Provide the Provider Directory to all beneficiaries. Provider Directory is available in threshold languages and can be obtained through the Call Centers, from providers, or on BHSD’s website.

  2. Upon referral or receipt of the referral, identify the designated person or entity primarily responsible for care coordination and provide the designated contact information.

  3. Obtain consent from the patient/guardian for ongoing communication relating to their treatment using the SCVHHS Authorization for Use or Disclosure of Protected Health Information.

  4. Coordinate physical health primary care assignments for beneficiaries who not have a primary care provider.

  5. Determine any biomedical, behavioral health, and community and social support needs as a part of the assessment. Assessments must include any special provisions for the target population such as age, gender, developmental appropriateness, culture, and type of systems or program involvement.

  6. Document care coordination needs in the care plan including goals that are achievable with objectives that are specific, measurable, and attainable with specific timelines for completion.

  7. Initiate the coordination of care needed, including linkage with other providers and institutions that serve the client population as appropriate.

  8. Provide coordination for transitions between all settings and levels of care, including collaborative discharge planning. For Mental Health transfers between MCO providers reference SCVHHS MH Policy #412-309 Client Transfer Between Specialty Mental Health Service Providers. There is a separate SUTS client transfer policy document.

  9. As appropriate, share and communicate beneficiary’s needs, relevant information for treatment, services, and referrals, and coordinate follow-up with other providers, in order to prevent duplication of services.

  10. Document referrals, progress toward the care plan goals and objectives, and coordination of care in progress notes using the appropriate service code.

  11. Will make every attempt to link beneficiaries to another network provider, when a beneficiary requests a change or transfer of providers, and the change is deemed clinically appropriate and possible [SCVHHS MH Policy #412-309 Client Transfer Between Specialty Mental Health Service Providers; Beneficiary Rights Policy #11400]. There is a separate SUTS client transfer policy document.

Utilization Management Program

​  MH MCP, Psychiatric Hospitals, and Institutions:

  1. Contact the Call Center to identify if the beneficiary has an existing provider or requires a referral.

  2. Coordinate between settings of care, including discharge planning consistent with the State and Federal requirements and Memorandum of Understanding with Santa Clara County’s Medi-Cal Managed Care Plans.

 SUTS MCP QI, Medical Hospitals, and Ambulatory Care:


  1.  Hospital and Ambulatory Care social workers coordinate care by contacting the Substance Use Treatment Services Managed Care Plan Quality Improvement Coordinator (SUTS MCP QI) when a beneficiary needs substance use services.

  2. The MCP QI approves and facilitates placement into the appropriate level of SUTS services.

 Quality Management: ​


  1. Regularly monitors provider coordination of care efforts through retrospective record reviews and audits.

  2. Provides training to and consultation for network providers to improve efforts to coordinate care.

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