Service coordination/case management
This domain tests whether you can move a person safely through a fragmented system: multiple providers, funders, guardians, and settings. Exam items typically focus on transitions, closed-loop follow-up, and clear accountability.
Core rules
- One accountable coordinator per transition. Name who is responsible for each step and the date it is due.
- Closed-loop referral. A referral is not complete when it is sent; it is complete when the result is received, acted on, communicated to the person and team, and documented.
- Medication reconciliation at every handoff - admission, discharge, day program change, new prescriber. Include over-the-counter drugs, topicals, and PRNs.
- Hospital transitions are high-risk. Confirm the discharge summary and medication list, obtain follow-up appointments, verify equipment and supplies, brief and train direct support staff on new instructions, and check the person's status within the first days home.
- Guardianship is not blanket authority. Know the scope of any guardianship, health care proxy, or supported decision-making arrangement, and involve the person in decisions to the maximum extent.
- Funder rules shape options. Waiver services, ICF/IID, and school-based services have different eligibility, documentation, and appeal processes; know which applies before promising a service.
- No-shows and lost results are coordination failures and should trigger follow-up, not a note in the chart.
Worked example
A man with cerebral palsy and a feeding tube is discharged after aspiration pneumonia. Coordination includes: reconciling the discharge medications against the home list and resolving two discrepancies with the prescriber; confirming the tube feeding order, formula supply, and pump; training the two staff who cover weekends on the new feeding schedule; scheduling the follow-up and the swallow evaluation; briefing the day program on restrictions; and a nurse check within 48 hours. Each item is assigned and dated, and the results are documented in one place.
Traps
- Assuming another agency has handled the follow-up.
- Sending a referral and never confirming the result.
- Accepting a discharge summary as complete when the medication list conflicts with the home record.
- Treating the guardian's consent as a substitute for the person's participation.
- Losing information between shifts or between settings.
- Promising a service before confirming eligibility.