Care coordination

1. The certified clinic shall coordinate care across the spectrum of health care services based on a person-centered and family-centered treatment plan that aligns with the requirements of section 2402(a) of the Patient Protection and Affordable Care Act of 2010 [Pub. L. No. 111-148], as amended by the Health Care and Education Reconciliation Act of 2010 [Pub. L. No. 111-152] and with state laws and regulations and is consistent with best practices. The coordination of care must include access to high-quality acute and chronic physical health and behavioral health care, social services, housing, educational systems, and employment opportunities as necessary to facilitate wellness and recovery of the individual. The certified clinic shall coordinate with other systems to meet the needs of the individuals they serve, including criminal and juvenile justice and child welfare. 2. The certified clinic shall maintain the necessary documentation to satisfy the requirements of the Health Insurance Portability and Accountability Act of 1996 [Pub. L. No. 104-191, 110 Stat. 1936], title 42, Code of Federal Regulations, part 2 and other federal and state laws and regulations. 3. To promote coordination of care, the certified clinic shall obtain necessary consents for sharing information with community partners and other systems if information is not able to be shared under the Health Insurance Portability and Accountability Act of 1996 [Pub. L. No. 104- 191, 110 Stat. 1936], title 42, Code of Federal Regulations, part 2, and other federal and state laws and regulations. If the certified clinic is unable, after reasonable attempts, to obtain the necessary consent for any care coordination activity specified in sections 75-03-44-23 through 75-03-44-26, such attempts must be documented and revisited periodically. 4. Consistent with requirements of privacy, confidentiality, and the preferences and needs of individuals, the certified clinic shall assist individuals and the families or legal representatives of the children referred to external providers or resources in obtaining an appointment and tracking participation in services to ensure coordination and receipt of supports. 5. The certified clinic shall coordinate care in keeping with the preferences of the individual and the individual's care needs. To the extent possible, the certified clinic shall provide care coordination, as appropriate, in collaboration with the legal representative of the adult individual, if applicable, and the adult individual's family or other supports to the extent the adult individual so wishes, or if the individual is a child, in collaboration with the family or legal representative if permitted by federal laws and regulations. 6. To identify the preferences of the individual in the event of a behavioral health crisis, the certified clinic shall develop a crisis plan with each individual. At minimum, the certified clinic shall counsel individuals about the use of the 988 suicide and crisis lifeline, mobile crisis, and stabilization services should a behavioral health crisis arise when providers are not in their office. 7. The certified clinic shall make and document reasonable attempts to determine any medications prescribed by other providers. If state laws and regulations allow, the certified clinic shall consult the state prescription drug monitoring program before prescribing medications. Upon appropriate consent to release of information or as otherwise authorized by federal and state laws and regulations, the certified clinic shall provide a list of medications prescribed by the certified clinic to other providers not affiliated with the certified clinic as necessary for safe and quality care. 8. A certified clinic may not limit the freedom of choice of an individual receiving care coordination services from choosing the individual's appropriate provider within the certified clinic, with its designated collaborating organizations or with any other provider, unless limited by federal or state laws or regulations. 9. The certified clinic shall assist individuals and families or the legal representatives to access benefits, including Medicaid, and enroll in programs or supports that may benefit the individuals and their families or legal representatives. 10. The certified clinic shall work with its designated collaborating organizations to ensure all steps are taken, including obtaining consent to release of information from the individual to comply with privacy and confidentiality requirements, including the Health Insurance Portability and Accountability Act of 1996 [Pub. L. No. 104-191, 110 Stat. 1936], title 42, Code of Federal Regulations, part 2 and other federal and state laws and regulations.