Clinical Practice & Care Coordination
Care Coordination & Referral Management
Coordinates complex care transitions across multiple systems (health, housing, justice); negotiates referral priorities and timelines; resolves scheduling and transportation barriers; ensures clinical information transfer via CCDs or care summaries.
Expected at Mid
Sample competency question
Ask once, as written, then allow silence. A helpful rephrase may hand the candidate the answer.
Credit
- Names specific coordination challenges overcome
- Describes communication rhythm with partners
- Mentions verifying service actually delivered
Discount
- Blames other agencies for breakdowns
- No example of multi-party coordination
- Left client to manage conflicts alone
Independent coordination across health, housing, and justice systems is essential to prevent service fragmentation and ensure successful transitions. Mastery at this level prevents clients from falling through systemic gaps, reduces resource duplication, and avoids costly hospital readmissions or homelessness.

