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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 advocate for and 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, visit RHIhub's Rural Care Coordination Toolkit.

Examples of Care Coordinator/Manager Models

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.

Resources to Learn More

Evaluation of the Frontier Community Health Care Coordination Network Grant
This policy brief presents the results of a care coordination program at the Montana Department of Public Health and Human Services, which received a Frontier Community Health Care Network Coordination grant from the Federal Office of Rural Health Policy. CHWs worked with referred community members 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
A description of how Grand-Aides, a specialized CHW program, carries out its services in a rural care delivery setting.
Organization(s): Partners in Health (PIH)

Health Coaches for Hypertension Control
Identifies a hypertension program providing health screenings and classes on topics such as high blood pressure, nutrition, physical activity and stress management.
Organization(s): Clemson University; Oconee Memorial Hospital; DHEC

Home Based Help with Health
Brochure identifies health coach services in three rural counties in South Carolina.
Organization(s): Clemson University; Oconee Memorial Hospital; DHEC

Improving Care Transition of Older Adults with Community Health Advisors
Presentation Slides
Overview of what a CHW is and the effectiveness of a CHW as a care transition coach for older adults. Also includes discussion on research, policy and research support for CHWs.
Author(s): Dye, C., Willoughby, D., & Aybar-Damali, B.
Organization(s): Gerontological Society of America
Date: 11/2009