Q&A: Care coordination
Q: What are the distinct roles of social work care manager versus community health worker?
A: Care coordination involves many levels of intervention. Social work care managers and community health workers have a variety of roles they can play which are case dependent. Below are common functions of the two positions.
Social work care manager
- Care plan development
- Address systemic barriers to care
- Integrate care among various providers, especially BH providers
- Assess substance abuse and mental health needs and assess patient readiness for change
- Address anxiety and trust issues
- Coach re: behavior change
Community health worker
- Meet with patient during hospitalization
- Arrange for post-acute home visit and other home visits as needed
- Facilitate transition to home from acute
- Appointment reminders and accompaniment
- Arrange transportation
- Arrange entitlements
- Link to community/home-based resources
- Teach patients self-monitoring strategies
For more information, see Case Management Models: Best Practices for Health Systems and ACOs, 2nd edition.