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This chapter provides accounts from two teams that highlight care coordination, case management, and system navigation. Care coordination, case management, and system navigation involve participating in care coordination and/or case management; making referrals and providing follow-up; facilitating transportation; documentation and tracking of data; and informing people and systems about community assets and challenges. The first team based out of Northeast Texas describes how a navigation system utilizing certified community health workers (CHWs) was established to provide system navigation to established patients, individuals using inpatient services, the emergency department, and surrounding community members in their area. Proper access to care and self-management are vital to improve health literacy, appropriate utilization of emergency departments, and the establishment of a medical home. The second team is a collaboration of those who work with assisting families of children with special healthcare needs (CSHCN). They document the development of Special Connections and the regional network of support for CHWs involved in assisting families of CSHCN. They discuss the reasons that CSHCN and their families can benefit from CHW engagement; highlight how the development of consensus for a specific focus on CSHCN is useful; and express the evolution of a regional partnership of CHWs, healthcare professionals, and educators to address the concerns of CSHCN. |
