Care Coordination & Systems Navigation

Coordination of care and system navigation for individuals and families means that CHWs help people understand and use the services of health providers and other service organizations. They also help address practical problems that may interfere with people’s abilities to follow provider instructions and advice. CHWs help bridge cultural, linguistic, knowledge and literacy differences among individuals, families, communities and providers. They help improve communications involving community members and agency or institutional professionals. CHWs understand and share information about available resources, and support planning and evaluation to improve health services.

During our training, participants will learn to:
  • Obtain and share up-to-date eligibility requirements and other information about health insurance, public health programs, social services, and additional resources to protect and promote health
  • Work collaboratively as part of a care team
  • Assist in developing and implementing care plans, in cooperation with clients and professional colleagues. (Care plans should be based on needs and resource assessments. Plans should describe how each party involved will help meet the goals and priorities defined in collaboration with clients.)
  • Provide care coordination, which may include but not be limited to facilitating care transitions, supporting the completion of referrals, and providing or confirming appropriate follow-up
  • Provide support for clients to use provider instructions or advice, and convey client challenges to providers
  • Provide support for people to understand and use agency and institutional services
  • Make referrals and connections to community resources to help individuals and families meet basic social needs
  • Build clients’ ability to participate in making decisions about their care
  • Inform care providers, to the extent authorized, about challenges that limit the ability of clients to follow care plans and navigate the health care system, including barriers outlined in the Americans with Disabilities Act
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