Service Coordination
Linking is an activity with an outcome
Service coordination (case management) covers needs assessment, service planning, linking to resources, monitoring, advocacy, and documentation of what actually happened. The counselor's job is to remove barriers and keep the client connected across systems - medical, psychiatric, housing, employment, legal, child welfare - while keeping the client in charge of decisions.
What good coordination looks like
- Releases of information that are specific, time-limited, revocable, and signed before any information moves. Without one, you may receive information from a family member but disclose nothing.
- Warm handoffs: direct contact between providers, a named contact person, and confirmation the client got an appointment.
- Follow-up: verifying the client engaged, not just that a call was placed.
- Transitions between ASAM levels of care with a written continuing-care plan and a scheduled first appointment.
- Multidisciplinary collaboration: sharing only the minimum necessary information, consistent with 42 CFR Part 2 and HIPAA.
- Advocacy: helping the client navigate systems and speak for themselves, not speaking over them.
- Documentation of referrals made, outcomes, barriers, and the client's preferences.
Traps
Treating a referral as complete when only a phone call occurred; sharing information without a release; making decisions for the client and calling it case management; stepping outside your scope (for example, giving legal or medical advice); failing to document follow-up attempts; ignoring practical barriers such as transportation, childcare, or work schedule.
Rule of thumb
A referral is finished when the client is engaged at the receiving service and that engagement is documented - not when you put down the phone.