Demo Intro My day Coalition admin Care coordination handoff

Care coordination handoff

RFI Scenario 3 · Transfer or share a participant record across providers or coalitions, with explicit visibility controls. All transfers are audit-logged; receiving parties see only what the sending side grants, and only for the duration specified.

Sending coalition

Glades Coalition

Belle Glade · Pahokee · South Bay
Rural western Palm Beach County. Handing off due to client relocation.

Rosa Guerrero

Current Case Manager

Participants

Case Mgrs

DQ score

Inter-coalition
transfer

Receiving coalition

Palm Beach Coalition

West Palm · Lake Worth · Boynton · Delray
Accepting based on client's new address in Lake Worth (33461).

Tamika Monroe

Proposed Case Manager

182

Participants

Case Mgrs

DQ score

Janelle Green

Participant #HSF-2025-GLD-03177 · 28 yrs · 34 wk pregnant · EN

Prenatal · 34 wk Relocating High-risk (preeclampsia)

Was: Belle Glade 33430 → Now: Lake Worth 33461 EDD May 28, 2026 OB: Lakeside OB/GYN (already in Palm Beach network) Medicaid active

Transfer type

Full transfer of care Recommended

Palm Beach Coalition becomes primary. Full participant record hands over. Glades retains read-only access for 30 days (continuity); audit log persists indefinitely. Use when the client is physically relocating.

Temporary share (co-management) Dual-coalition

Both coalitions co-manage for a defined period (e.g., client splits time between two counties). Both can write to the record; conflicts surface in a reconciliation queue.

Read-only share (consult) View only

Receiving coalition can view specified fields only, for a specified duration. Often used for second-opinion reviews or referrals that don't transfer care.

Visibility & permission matrix

Data element	Glades (sender) After transfer	Palm Beach (receiver)	State (HSF)
Demographics & contactName, address, phone, DOB
Risk screeningsPrenatal, postpartum, EPDS, HITS
Case notesFree-text documentation
Services & visits logHome visits, phone contacts, screenings
Referrals & outcomesExternal referrals, acknowledgment status
Birth outcome & infant recordDelivery, weight, NICU, well-child
Medicaid ID & insuranceClaims & eligibility
IPV & safety-sensitive fieldsHITS screen, safety plan
Consent documentsHIPAA, program, transfer consent
Audit logWho viewed / changed what & when

Read / write Read-only De-identified rollup Audited (need-to-know) Not shared

Transfer context

Reason for transfer

Effective date

Sender read-only access expires

Notes for receiving case manager

Client notified & consent re-confirmed

Consent re-confirmed by phone on 4/21 · verbal consent logged by Rosa Guerrero. Signed form collected at next visit.

Transfer history — this coalition

Miami-Dade → Palm Beach

3 days ago

Yanelis Fuentes · Relocation · 32 wk pregnant

Accepted by Maria Alvarez · full-transfer handoff

Accepted

Palm Beach → Broward

Yesterday

Tiffany Watts · Relocation · 6 wk postpartum

Sent to Broward Healthy Start · full transfer · awaiting acceptance

Pending receiver

NE Florida → Palm Beach

2 wk ago

Brianna Cole · College relocation

Accepted · assigned to Jasmine Barnes (Riviera)

Accepted

Palm Beach → Tampa Bay

5 wk ago

Alexis Park · Relocation

Declined by receiver · client did not complete re-consent

Declined

Orange / Seminole ↔ Palm Beach

7 wk ago

Deja Holloway · Co-management

Shared access (temporary) · client works week-on/week-off between counties

Co-managed

Pre-transfer data-quality check

Risk screen on file — prenatal risk completed 2/14/26

All consents signed — HIPAA + program + transfer

Care plan not updated since 3/28 — recommend refresh before handing off

No open referrals pending action from Glades

Medicaid eligibility verified — last check 4/19

Audit trail preview

On submit, the following will be logged (immutable, viewable by state + both coalitions):

2026-04-22 14:32 transfer.initiated
actor = [email protected]
participant = HSF-2025-GLD-03177
type = full_transfer
receiver = palm-beach-coalition
retention_days = 30 (sender read-only)
consent_verified_by = phone 2026-04-21
2026-04-22 14:32 audit.notify
notify = [email protected], denise.patterson@...