What a care coordination plan is
A care coordination plan is the operating sheet for a care team. A treatment plan sets clinical goals and a care plan pulls every condition into one document. The coordination plan sits underneath both and deals with logistics: names, roles, phone numbers, what has been consented to, who sends what to whom, and by when.
HIPAA treats this work as treatment. The Privacy Rule defines treatment to include "the coordination or management of health care" by a provider with a third party, consultation between providers and referrals (45 CFR 164.501). That definition is what lets most of the plan run without a signed authorization for each call, with two exceptions covered further down.
Care coordination plan or another plan?
| | |
|---|
| Who does what, who talks to whom, what's still open | Care coordinator or case manager |
| What the team is trying to achieve for all of the patient's conditions | Primary care team or care manager |
| One clinician's goals, objectives and interventions | Treating therapist or psychiatrist |
| What must be in place before the patient leaves a facility | |
| One handoff to one new provider | |
What each section holds
| |
|---|
| Client details, the lead coordinator, and a backup when the coordinator is out |
| Every provider and support person, their role, contact details and preferred channel |
| For each person on the roster: shared under HIPAA treatment rules, under a signed consent, or not to be contacted |
| Two or three goals the whole team agrees on, copied from the treatment or care plan |
| Each task with one owner and a due date |
| Standing calls, case conferences and what triggers an unscheduled contact |
| Upcoming admissions, discharges, moves or changes of provider, and who covers each one |
| Referrals sent and not confirmed, results not received, appointments not booked |
| |
Care coordination plan example
Marisol (fictional), 34, receives services at a community mental health center for bipolar II disorder. She has been in an opioid treatment program for eight months and gets buprenorphine there. A primary care physician manages her asthma, a peer recovery specialist meets her weekly, and she is on a waitlist for supported housing. Her sister drives her to most appointments. The center's care coordinator wrote this plan after a case conference on October 14, 2026.
| Marisol's care coordination plan |
|---|
| F31.81, bipolar II disorder. F11.21, opioid dependence, in remission, which in the FY2027 tabular list includes opioid use disorder, severe, in early remission. |
| Care coordinator at the community mental health center. Backup: the center's intake supervisor. |
| Psychiatrist and therapist at the center: same organization. Primary care physician: treatment disclosure under HIPAA. Opioid treatment program counselor and prescriber: Part 2 consent signed October 14, covering treatment, payment and operations. Peer recovery specialist: signed consent. Housing agency: signed consent, limited to housing status and appointment dates. Sister: Marisol agreed she can be told appointment times only. |
| No hospital stay through April 2027. Keeps all buprenorphine and psychiatry appointments. Moves into supported housing. |
| Psychiatrist sends the medication list to the opioid treatment program after every change, within 2 business days. Opioid treatment program prescriber tells the psychiatrist of any dose change. Primary care physician checks her asthma medicines against the psychiatrist's medication list by November 15. Coordinator calls the housing agency every two weeks. |
| Monthly 20-minute case call, second Tuesday. Same-day call to the coordinator if Marisol misses a dosing day, reports a mood episode or goes to the emergency department. |
| Housing offer expected in early 2027. Coordinator confirms her new address is within reach of the program's dosing site before she accepts. |
| Lung function test result from primary care, not received. Peer specialist's contact sheet, requested October 14. |
| January 13, 2027, or sooner after any hospital stay |
Every responsibility has one owner and a deadline, and the consent column says exactly what each person on the roster may receive. When a new provider joins, the coordinator adds them to the roster with their consent status before anyone sends them a record.
Most of what moves between treating providers is a treatment disclosure. 45 CFR 164.506(c) lets a covered entity disclose protected health information for the treatment activities of another health care provider, and the minimum necessary standard doesn't apply to disclosures to a provider for treatment (45 CFR 164.502(b)(2)). State laws can be stricter, so check yours.
Psychotherapy notes are the first exception. Sharing them requires the client's authorization even for treatment, apart from narrow cases such as use by the clinician who wrote them (45 CFR 164.508(a)(2)). Send the progress note, diagnosis and plan instead.
Substance use records and 42 CFR Part 2
The second exception is substance use disorder treatment records from a Part 2 program. A program, under 42 CFR 2.11, is a provider or an identified unit that holds itself out as providing, and provides, substance use disorder diagnosis, treatment or referral for treatment. An opioid treatment program like Marisol's usually qualifies. A general medical practice that prescribes buprenorphine as part of its other care may not, so ask each provider whether they operate as a Part 2 program.
Part 2 records need the patient's written consent. The current consent rule, 42 CFR 2.31, allows a single consent for all future uses and disclosures for treatment, payment and health care operations, and the recipient can be described as "my treating providers, health plans, third‑party payers, and people helping to operate this program" or something similar. Record the date and scope of that consent in the roster, as in Marisol's plan.
Blank care coordination plan template
- Client name, date of birth, plan date:
- Lead coordinator and backup, with contact details:
- Diagnoses with ICD-10-CM codes:
- Care team roster (name, role, organization, phone, preferred channel):
- Consent status for each roster entry (HIPAA treatment / signed consent and date / Part 2 consent and scope / do not contact):
- Family or other supports, and what the client agreed they may be told:
- Shared goals (two or three):
- Responsibilities (task, owner, due date):
- Communication schedule and triggers for an unscheduled contact:
- Upcoming transitions and who covers each:
- Open loops (item, owner, date requested):
- Next review date:
Common mistakes
- "Team to follow up" as an owner. If a task has no single name next to it, nobody does it.
- A roster with no consent column. Staff then either over-share Part 2 records or refuse to share anything.
- Closing a referral when it is sent instead of when the new provider confirms the first appointment.
- No plan for the coordinator's absence. A two-week vacation is long enough for a missed dosing day to go unreported.
- Copying session content into the plan. It travels to every member of the team, so keep it to logistics and shared goals.
Writing coordination notes with Twofold
Case conferences and coordination calls produce a lot of small commitments. Twofold can draft the meeting summary from the recorded call, and with a custom template you can have it list each task with its owner and date so they drop straight into the responsibilities section. You check the draft before it goes into the record.
Plans that feed this one: the care plan, treatment plan, chronic care management template and discharge planning template. For individual handoffs, use the patient referral form. Day‑to‑day contacts go in case notes.
Reviewed and updated October 2026.
