Care coordination partnerships

1. The certified clinic shall have a partnership establishing care coordination expectations with federally qualified health centers located in the certified clinic service area to provide health care services, if the services are not provided directly through the certified clinic. For individuals who are served by other primary care providers, including federally qualified health center look-alikes and community health centers, the certified clinic shall establish protocols to ensure adequate care coordination. 2. The certified clinic shall establish partnerships for care coordination expectations with programs, including tribal programs, if any exist within the certified clinical service area, that can provide inpatient behavioral health treatment, opioid treatment program services, medical withdrawal management, ambulatory medical withdrawal management for substance use disorders, and residential substance use disorder treatment. 3. The certified clinic shall track when individuals are admitted to facilities providing the services listed in subsection 2, and when individuals are discharged, unless there is a formal transfer of care to a noncertified clinic entity. 4. The certified clinic shall establish protocols and procedures for transitioning individuals from emergency departments, inpatient behavioral health programs, medically monitored withdrawal management services, and residential or inpatient facilities that serve children to a safe community setting. The certified clinic's established protocols and procedures must include the transfer of health records of services received, a plan to follow up actively after discharge, and, as appropriate, a plan for suicide prevention and safety, overdose prevention, and provision for peer services. 5. The certified clinic shall establish partnerships with a variety of community or regional services, supports, and providers. The certified clinic's partnerships shall support joint planning for care and services, provide opportunities to identify individuals in need of services, enable the certified clinic to provide services in community settings, enable the certified clinic to provide support and consultation with a community partner, and support certified clinic outreach and engagement efforts. 6. A certified clinic shall develop partnerships with the following community or regional services, supports, and providers that provide services within the certified clinic's service area: a. Schools; b. Child welfare agencies; c. Criminal and juvenile justice agencies and facilities, including jails and other specialty courts; d. Treatment facilities, mental health facilities, facilities serving veterans, and facilities serving individuals with brain injury; e. Indian health service youth regional treatment centers; f. State licensed and nationally accredited child-placing agencies for therapeutic foster care service; and g. 988 suicide and crisis lifeline call center. 7. The certified clinic shall establish a partnership with the nearest department of veterans' affairs medical center, independent clinic, drop-in center, or other facility of the department of veterans' affairs. If multiple department of veterans' affairs facilities of different types are located in the certified clinic's service area, the certified clinic shall work to establish care coordination agreements with facilities of each type. 8. The certified clinic's care coordination partnerships shall establish expectations with inpatient acute-care hospitals in the certified clinic's service area and with the inpatient acute-care hospital's associated facilities, including emergency departments, hospital outpatient clinics, urgent care centers, and residential crisis settings. The certified clinic's care coordination partnerships' expectations must include procedures and services to help individuals successfully transition from emergency department or hospital to the certified clinic and community care to ensure continuity of services and minimize the time between discharge and followup. The certified clinic shall work with the discharging facility ahead of discharge to assure a seamless transition. The certified clinic's partnerships shall support tracking if individuals are admitted to facilities providing the services in this subsection, and if the individuals are discharged. The certified clinic's partnerships shall support the transfer of health records of services received and provide for active followup after discharge. 9. The certified clinic shall make and document reasonable attempts to contact all individuals who are discharged from the facilities providing services in subsection 8 within twenty-four hours of discharge. For all individuals being discharged from facilities providing services in subsection 8 who are at risk for suicide or overdose, the care coordination agreement between facilities providing services in subsection 8 and the certified clinic must include a requirement to coordinate consent and followup services with the individual within twenty-four hours of discharge and must continue until the individual is connected to services, assessed to be no longer at risk, or refuses care. 10. The certified clinic shall attempt to enter a formal, signed care coordination agreement detailing the roles of each party. At a minimum, the certified clinic shall develop written protocols for supporting coordinated care undertaken by the certified clinic and efforts to deepen the partnerships required by this section over time so jointly developed protocols or formal agreements may be developed.