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Rural Health Information Hub

Formerly the
Rural Assistance Center

Care Coordinator/Manager Model

As a care coordinator or care manager, community health workers (CHWs) help individuals with complex health conditions to navigate the healthcare system. They liaise between the target population and a variety of health, human, and social services organizations. CHWs also support individuals by:

  • Providing information on health and community resources
  • Coordinating transportation
  • Making appointments
  • Delivering appointment reminders

CHWs may work with patients to develop a care management plan and use tools to track their progress over time (e.g., food and exercise logs). For example, in one rural CHW program, CHWs served as a care transition coach for rural elders who were discharged from home health services. In another rural program, CHWs contacted patients who were recently diagnosed with a chronic disease to answer questions and make appointments.

To learn more about the role of care coordinators, see the Care Coordinator Model in Rural Health Information Hub’s Care Coordination Toolkit.

Implementation Considerations

In this model, the CHW provides case management to individuals who have chronic conditions and/ or individuals who need help navigating the health system. The CHW may encounter questions or situations that require help from trained health professionals. Programs may pair CHWs with a medical professional whom they can call with questions. CHWs must understand the procedures associated with an emergency (e.g., nearest hospital, who to call, their scope of practice and responsibilities) and have a strong understanding of the healthcare system and resources available in their community. CHWs that serve as a care coordinator or care manager often receive disease-specific education and training.