Keep Care Connected

Coordinate CareCARE Step 2 · Keep Care ConnectedRecord and Communicate

By the end of this module, you can: keep unfinished work visible, use a warm handoff when responsibility moves, confirm the next person or service actually starts the work, and repair the plan when something is dropped.

Approximately 15–20 minutesTrack → Hand Off → Confirm → Repair

What Continuity Means

Coordination connects the student with resources.

Continuity makes sure those connections do not fall apart.

A good plan can fail when:

• a shift ends;
• the student changes locations;
• transportation begins;
• a provider accepts only one part of the case;
• important information does not reach the next person;
• the student does not know what happens next;
• everyone assumes someone else is responsible.

Continuity means the important parts of the plan stay connected until the work is actually underway or complete.

Do this

Keep the student informed

Tell the student what is changing, who is taking over, what will happen next, and what they should do if the plan does not happen.

Whenever possible, include the student in the handoff rather than talking around them. Preserve the communication method, privacy, supports, and choices that helped the plan work.

Do not overlook

If Risk Changes, Reassess

CARE continues only while the student remains stable enough for the current plan. If safety, medical condition, suicide risk, behavior, communication, or ability to use the plan changes, reassess and return to the appropriate SAFE step or emergency route.

Scenario

Opening continuity problem

Several parts of the plan are moving at the same time

A student is leaving a staffed waiting room for a same-day clinical appointment. Housing is still reviewing an afternoon placement. The student uses typed communication when overwhelmed.

The driver knows the clinic address but not the housing deadline. The clinic knows about the earlier crisis concern but not the student’s communication needs. The day-shift coordinator has not accepted the overnight case.

What is the biggest problem?

The case could split apartKeep the open needs visible, protect the supports that must continue, and transfer responsibility only when the next person accepts it.The driver might be lateFocus only on getting the student to the clinic on time.The clinic owns everything nowRelease the housing and campus work once the student leaves for the appointment.

Keep the Plan Connected

Track→Hand Off→Confirm→Repair

1

Track

Keep the open work visible.

Know what is still happening, who currently owns each part, what the student needs to keep using the plan, and which deadlines or dependencies matter.

Result: You can see what must continue even when people, shifts, locations, or services change.

Track only what matters to the active plan: clinical follow-up, housing, transportation, communication support, access, academic needs, advocacy, basic needs, or another unresolved function.

2

Hand Off

Use a warm handoff when responsibility moves.

Connect the current owner directly with the next person or service whenever the work is important enough that a dropped handoff could harm the student or break the plan.

Result: The receiving person knows what they are taking over, the student knows what is happening, and the current owner knows what responsibility remains.

A warm handoff is more than sending information. It includes a direct connection, a clear request, acceptance by the receiver, and a known first action.

What a Warm Handoff Looks Like

A warm handoff should answer four simple questions:

Do this

What is being handed off?

Name the specific need or task: clinical intake, housing follow-up, transportation, advocacy contact, academic support, or another defined function.

Pass forward

What does the next person need to know?

Share the current condition, important history, timing, student preferences, communication or access needs, and anything that could make the plan fail.

Stay within your role

What did they accept?

Hear the receiving person or service clearly accept the work they are taking over. Do not assume that receiving an email, voicemail, or record means responsibility transferred.

Do not overlook

What still remains yours?

Keep anything that was not accepted. One successful handoff does not automatically transfer the entire case.

Do this

Include the student when possible

A strong warm handoff often happens with the student present or aware of the transfer. Introduce the next person, explain what they will do, confirm the student’s communication and access needs, and let the student ask questions or correct important information.

3

Confirm

Make sure the next step actually starts.

Do not stop at “they got the message.” Confirm that the receiving person or service can act and that the student can use the next step.

Result: The plan has moved from referral or acceptance into actual action.

Examples: the clinic begins intake, transportation arrives, the day coordinator contacts housing, the student enters the temporary placement, or the scheduled support call actually occurs.

4

Repair

Fix what gets dropped.

If the connection fails, identify what was lost, keep or restore temporary support, assign someone to fix it, and update the student.

Result: The student is not left between services with no owner and no plan.

Repair may mean finding another provider, restoring transportation, reconnecting communication support, escalating an unanswered handoff, extending a waiting arrangement, or returning to SAFE when the failure changes risk or immediate function.

Knowledge Check

Warm handoff

The clinic accepts only the clinical work

The clinic confirms it will begin clinical intake at 14:00 and can use typed communication. It cannot monitor the housing deadline or arrange the student’s return.

The day-shift coordinator answers but says, “Send me the notes and I will look at them later.”

What should happen?

Release the whole caseThe clinic and day shift both received information, so the overnight coordinator can leave.Keep the unaccepted work and complete the handoffLet the clinic own clinical intake, keep housing and overall coordination with the current owner, and get explicit day-shift acceptance before release.Cancel the clinic visitThe clinic cannot take housing, so the handoff is incomplete and should not happen.

Across Shifts

Shift change is one of the easiest places for continuity to fail.

Before leaving:

• name the open work;
• identify the next owner;
• make the warm handoff;
• correct the student’s expectations;
• confirm the next owner’s first action;
• keep responsibility until acceptance is clear.

Shift change

A detailed report was sent, but no one accepted the case

A resident is in a temporary room until noon. A conduct interview and advocacy contact are scheduled for the morning.

The night supervisor emails a detailed report to the day team at 06:55 and leaves at 07:00. The shared queue shows delivery, but no person acknowledges the case. The resident believes the night supervisor will call at 09:00.

Is the handoff complete?

Yes. The written report was delivered.The day team has the information, so the night supervisor can release ownership.Have the resident call the day teamThe student can take responsibility for making sure the case is picked up.No. Get closed-loop acceptance.Keep or escalate current ownership until a day role accepts the case, names the first action, and the student is told who will contact them.

Before You Move On

CARE Continuity Check

The plan is connected when

Open work

The important unfinished tasks and deadlines are still visible.

Owner

Someone clearly owns each active task until another person accepts it.

Warm handoff

Important transfers include a direct connection, clear request, acceptance, and known first action.

Student understanding

The student knows who is taking over, what happens next, and what to do if the plan fails.

Supports preserved

Communication, access, transportation, waiting arrangements, privacy, and other needed supports survive the transition.

Follow-through confirmed

The next action actually begins, or someone continues to own the gap until it does.

Move to Record and Communicate when

the open work is visible; every active task has a clear owner; important transfers are accepted through a warm handoff; the student understands the next step; needed supports survive the transition; and the next action has started or the waiting period still has an owner.

Repair continuity when

a handoff is not accepted, a shift or location changes, information or support is lost, the student cannot use the next step, the receiving service does not act, ownership becomes unclear, or another part of the plan is dropped. Reassess and return to SAFE when risk or immediate function changes.

Final Knowledge Check

New situation

Transportation arrives before the next service is ready

A student is scheduled to leave campus for an outpatient appointment. Transportation arrives on time, but the clinic says the appointment was moved back by two hours. The student has no food, their phone battery is low, and the current waiting room closes in 30 minutes.

The driver says they can either leave now or cancel the ride.

What is the best continuity response?

Send the student nowTransportation is already present, so preserving the ride should take priority.Repair the plan before movementConfirm the new clinic time, arrange a safe waiting option and basic needs, preserve phone access, update transportation, and keep ownership until the revised connection is workable.Cancel everythingThe schedule changed, so the clinical plan is no longer usable.

Pass Continuity into the Record

Record and Communicate begins with the continuity picture you have maintained.

Carry forward:

• what work is still open;
• who owns each task;
• what was handed off and accepted;
• what the next person or service actually started;
• what the student was told;
• what supports must remain in place;
• what failed or changed;
• what will require another check, repair, or return to SAFE.

The next CARE step creates the durable record that lets everyone continue from the same current picture.

Next · CARE Step 3

R — Record and Communicate

The plan is connected across people and services. Now create the clear record and communication that let the next authorized person continue the work.

Continue to Record and Communicate →