Care Coordinator/Manager Model
As care coordinators or care managers, community health workers (CHWs) help individuals with complex health conditions to navigate the healthcare system. In this model, CHWs support individuals by:
- Advocating for patient needs
- Liaising between patients and health and human services organizations
- Providing information on health and community resources
- Delivering health education
- Coordinating transportation
- Making appointments
- Delivering appointment reminders
In this model, CHW activities center around meeting patient care needs and preferences. For example, 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 our Care Coordination Models for Chronic Disease Management in the Rural Chronic Disease Management 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.
Implementation Considerations
In this model, CHWs provide case management to individuals who have chronic conditions and those who need help navigating the healthcare system. CHWs may encounter questions or situations that require support from health professionals who have received specific clinical training, such as doctors, nurses, or other medical professionals. To 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 have a strong understanding of the healthcare system and resources available within their community — for example, knowing the location of the nearest hospital, who to call in an emergency, and their scope of practice and responsibilities. CHWs who serve as a care coordinator or care manager often receive disease-specific education and training.
Technology is increasingly important to support CHWs, especially in this model. Technology can improve care coordination by helping CHWs identify and track referrals and next steps for clients and by supporting information-sharing with other providers and services.