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Rural Health Information Hub

Care Coordinator/Manager Model

As a care coordinators or care managers, community health workers (CHWs) help individuals with complex health conditions to navigate the healthcare system. They advocate for and liaise between their patients and a variety of healthcare and human services organizations. In this model, 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 such as food and exercise logs to track progress over time. In one rural CHW program, CHWs served as care transition coaches for older adults living in rural communities 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, visit RHIhub's Rural Care Coordination Toolkit.

Examples of Rural Care Coordinator/Manager Models

  • The Outer Cape Health Services Community Resource Navigator Program works to train and deploy CHWs to connect residents of Cape Cod, Massachusetts to social, behavioral health, and substance use disorder services.
  • In rural Pennsylvania, the Nurse Navigator and Recovery Specialist Outreach Program provides case management services to help patients with substance use disorder and chronic disease to navigate the healthcare system and access resources.
  • CHWs working at Kentucky Homeplace provide residents of rural eastern Kentucky with a variety of services, including access to medical, social, and environmental support services including diabetic supplies, eyeglasses, and home heating assistance. They also deliver education messages.

Implementation Considerations

In this model, the CHW provides case management to individuals who have chronic conditions and those who need additional help navigating the healthcare system. The CHW may encounter questions or situations that require help from clinically-trained health professionals. To help ensure CHWs have access to a resource to address these issues, programs may pair CHWs with a healthcare professional whom they can call with questions. In addition, CHWs must understand the procedures associated with an emergency — for example, knowing the location of the 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 who serve as a care coordinator or care manager often receive disease-specific education and training.

Program Clearinghouse Examples

Resources to Learn More

Evaluation of the Frontier Community Health Care Coordination Network Grant
Presents the results of a community-based, patient-centered clinical service coordination and health promotion project whereby a centrally located care transitions coordinator managed CHWs across a network of primary care providers and 11 Critical Access Hospitals (CAHs) to improve care transitions and health outcomes in an effort to reduce hospital admissions and readmissions.
Organization(s): Federal Office of Rural Health Policy, Health Resources and Services Administration
Date: 9/2015

Grand-Aides Program: Rural Care Delivery
Describes how Grand-Aides, a specialized CHW program, carries out its services in a rural healthcare delivery setting.
Organization(s): Grand-Aides