Q&A: Care coordination

July 12, 2017
Medicare Web

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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