CHW Care Coordination Process

What is care coordination?

In healthcare, "care coordination" means organizing and managing patient care activities and sharing information among everyone involved in providing care. This lesson provides a basic overview of the typical process a Community Health Worker engages in as they manage a case — from initial engagement with the patient, through the care coordination process, to the termination of a case.

Care coordination is "the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of healthcare services."

The amount of time CHWs spend working with a person differs by program and patient need, but the care coordination process usually has five phases.

The five phases of care coordination

Phase 1: Introduction & Enrollment

Depending on the program, the first step may be called outreach, engagement, enrollment, or recruitment. Your initial call to schedule the first visit is a great opportunity to begin building rapport. Starting the conversation can be challenging, so having a loose script ready makes it easier to focus on the message instead of finding the right words.

First impressions matter. CHWs who are nervous about their first encounters might find it useful to practice their scripts a few times before contacting patients.

When people decline

You may not know someone's preferred language, or they may encounter technical difficulties during your call. Being prepared helps you successfully engage with the patient. Sometimes people choose not to participate. Common reasons:

• They don't understand what the program is.
• They don't understand how the program will help them.
• They don't understand the time and effort commitment.

How to respond to resistance

Once you've broken the ice, observe the patient's body language and reactions to understand how they feel. CHWs have different ways to help patients overcome worries and resistance.

Handling resistance

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Phase 2: Screening & Assessment

Once the program has been introduced and the patient consents to enrollment, the next phase is an in-depth assessment of the patient's needs, risks, and strengths.

Key terms

Key assessment terms

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What to assess

Screening means gathering information about a person's background and asking questions carefully to find out whether they might have a specific problem or disorder. The goal is to decide if they need more detailed evaluation. Screening usually uses tests that are the same for everyone, and CHWs use that general information to figure out what other evaluations are necessary.

CHW assessments concentrate on risks and strengths in three main areas:

• Social determinants of health
• Social, emotional, and mental health
• Physical and functional health

"Risk" means things that could make a person's health worse — living situation, mental and social health, physical health and abilities. "Strengths" are the good things about a person and their surroundings that protect against illness; strengths get leveraged during care planning to address identified needs.

Initial Evaluation

CHWs use screening tools and choose assessments during the initial evaluation in order to better understand an individual's risks and strengths. These assessments typically include:

• A partially structured interview process
• The use of strategically chosen formal assessments

By using interviews and assessments, it allows us to learn more about a person's life and gather extra information about the areas of risk and strength that may have been identified in the screening tool. This will assist us in better understanding an individual and their situation.

Areas of Risk and Strength to explore

Formal assessment tools

Some examples of formal assessments CHWs may use to determine SDOH risks, social and mental health, and physical and functional health:

Common formal assessments

Match each assessment term to its definition.

A patient says they don't see why they should join the program. Which response best reflects how a CHW handles resistance?

Phase 3: Action Planning

After screening and initial assessment, the CHW has a much better picture of where the patient's care is lacking and what strengths can be leveraged. Now it's time to set goals and build a plan together.

Setting goals together

Based on identified needs, the CHW and patient work together to come up with four to six goals. When deciding which goals matter most, consider why the patient was referred, what needs were found through screenings and assessments, the patient's safety, what the CHW has noticed, and what matters most to the patient. Goals should be:

• Tangible
• Specific to CHW work
• Achievable within the program's parameters and timeline
• Aligned with what matters most to the patient

Putting the patient first

It's important to consider how a person feels and what they believe about their healthcare experience. When we prioritize what the patient wants, it shows they're actively involved — building a good relationship and leading to better results. Sometimes you need to talk through goals with the patient to ensure they match the CHW program and are doable.

Goal-setting: from draft goal to a better goal

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An action plan is the roadmap for how the patient, with your support, will achieve the goals you have come up with together.

Creating an action plan — 4 components

Example: Mary's fall-prevention plan

Goal 3: Mary will implement practices to prevent falls while bathing.

1. CHW coordinates with the insurance company to obtain authorization for grab bars to be installed within 6 weeks; CHW monitors the process.
2. Mary obtains a referral for occupational therapy (OT) from her PCP at the November 7th visit. CHW assists with scheduling OT appointments and arranging transportation.
3. Mary's spouse provides standby assistance while bathing until grab bars are installed and OT verifies she's ready to bathe independently.
4. If falls continue with standby assistance, CHW facilitates training for the spouse to provide hands-on assistance.
5. CHW evaluates fall risk after 3, 6, and 9 months.

Phase 4: Care Coordination & Management

This is the stage where the action plan is carried out. The CHW's main job is to make sure all the steps are done on time.

The 6 steps of coordination

Care coordination steps

Goal status indicators

Goal status

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Barriers to accessing resources

CHW work is fundamentally about connecting people with resources, but it's not always straightforward. Barriers fall into five categories — each with strategies to navigate them.

Five barriers to resources — and strategies

Phase 5: Case Termination

Ending your work with a patient is an important — sometimes difficult — part of coordinating care. When you finish a case, it usually means you've completed the care plan, achieved the goals, and confirmed ongoing support. During termination, the CHW formally ends their involvement.

During this conversation, explicitly highlight the patient's strengths and achievements. Remind them they are very capable of making changes after you're no longer collaborating.

When the intervention ends, some goals may still be in progress. Let the patient know that's normal and point out the progress made so far. If they applied for a benefit but haven't received approval yet, remind them when to expect a response. Give them a summary of remaining tasks and explain their role in following up.

When finishing with other healthcare providers, "close the loop" — tell them what was achieved, what comes next, and the strengths you noticed in the patient. This builds a stronger network of care, and a customer-service mindset makes future collaboration easier.

A patient needs a resource, but it isn't available in their preferred language and is out-of-network (Barrier 4). Which strategies fit this barrier? Select all that apply.

What is the correct order of the five-phase CHW care coordination process?