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. Author manuscript; available in PMC: 2017 Dec 18.
Published in final edited form as: J Health Care Poor Underserved. 2016;27(4A):91–115. doi: 10.1353/hpu.2016.0181

Level Definition

Significant Service Care coordination with individuals with multiple, complex, persistent needs in multiple systems (physical, social, behavioral health). Includes development of care plan and systematic working through it.
Short-term Service Needs met through short-term care coordination, including education, referrals, and follow up.
Referral/No Service Referral received and service offered. Engagement unsuccessful.