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.

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