Community Care Coordination – The Marriage of Health and Social Service Providers


Communities are struggling to find ways to improve outcomes for individuals and reduce the overall financial burden of providing care. There is a lot of discussion about how best to go about this and one area currently receiving attention is community care coordination. There is confusion, however, about what the term, “community care coordination,” actually entails. One reason for this stems from a lack of collaboration between providers of health and social services. Consequently, providers tend to understand care coordination in different ways. In order to provide some clarity, here are the who, what, where, and how of community care coordination.

What is Community Care Coordination?

  • Federal, State, and local agencies
  • Community-based organizations
  • Safety net clinics
  • Health plans
  • ACO/MCO’s
  • Local public health departments
  • Private practitioners
  • Hospitals

There are various models for accomplishing community care coordination. These models are typically described as medical neighborhoods or community health neighborhoods and include ACOs, MCOs, and Medicaid Waiver programs. Community health neighborhoods provide the infrastructure, systems, and processes that link an array of providers into a tightly coordinated team to provide whole-person care coordination for all patients in the neighborhood. In addition, these health providers are linked to a network of community support providers including housing services, faith-based organizations, job training, and child and family services that address the social determinants of health. A high-functioning health neighborhood:

  • Ensures effective communication, coordination, and integration with other providers
  • Ensures the efficient flow of patient data
  • Supports enhanced access and patient-centered, high-quality care through a Comprehensive Health Record
  • Improves patient outcomes
  • Delivers evidence-based care and improved population health

In essence, community care coordination addresses the social determinants of health while integrating primary and behavioral health in order to deliver high-quality, whole-person care. Now that we know the definition of community care coordination, let’s consider the key players involved.

Case Manager vs. Care Manager vs. Care Coordinator

Because community care coordination is a relatively new concept, there is confusion around the individual contributors who make care coordination happen. We hear of case managers, care managers and care coordinators but their titles and responsibilities are often interchanged. We’d like to clear up some of the confusion by providing definitions of these three important roles.

A case manager is focused on assessing individuals to determine if they are eligible for specific programs (i.e. food stamps), enrolling them in the program, and then tracking their progress. Their goal is to improve an individual’s overall wellbeing through enrollment in these programs. In general, case managers work with human service programs such as housing, workforce services, child and family services, food assistance, etc.

A care manager works more directly with patients to manage their health conditions and reduce the need for additional medical services. Care managers are traditionally found in hospitals and other clinical settings and often work with patients with chronic illnesses. Care managers may refer patients to multiple providers within the facility or health system, but they mainly focus on the medical needs of a patient.

Care coordination is where case management and care management come together. A care coordinator (or patient navigator) is a relatively new concept that primarily evolved due to the Affordable Care Act. The concept focuses on treating both the medical needs and the social factors (the social determinants of health) that affect the health of an individual. A care coordinator has visibility into all aspects of an individual’s care and serves as the point of contact for patients as they work with providers across the spectrum of care.


Now that you know the definition of community care coordination and the players involved, where do you get started implementing these concepts? The Agency for Healthcare Research and Quality (AHRQ) has a helpful resource called “Connecting Those at Risk to Care: The Quick Start Guide to Developing Community Care Coordination Pathways.” Also, if you are interested in an in-depth example of community care coordination for a vulnerable population, please see our white paper “Evolving Care Models Demand Community Care Coordination.”

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