Learn It
Live It
Share ItCare Coordination and System Navigation
in the Academy
🧭 Welcome, future CHW!
Get people to the right care in the right order (includes DHN Pro). This unit is 24 hours of CHW Foundations and CHW Pro training across video lessons, group practice, this eBook and the Qwest station.
By the end you can
- Map the local health and social service system
- Make warm handoffs and close the loop on referrals
- Use digital tools (portals, telehealth, devices) through Digital Health Navigator Pro
AZ scope area: Providing care coordination, case coordination and system navigation · AZ core competency: Service coordination and navigation
This unit includes all 24 hours of Digital Health Navigator Pro. If you already finished DHN Pro, those hours count here.
Care Coordination and System Navigation
What care coordination is
Helping a client get the right services in the right order, and making sure the pieces connect. You coordinate and follow up. The client decides, and the care team makes the medical decisions.
Know the system
Primary care, specialists, urgent care, the emergency room, pharmacies, behavioral health and community services all work differently. So do Medicaid (AHCCCS in Arizona), Medicare and Marketplace plans. Know who to call for what.
Warm handoffs and closed loops
A warm handoff means you connect the client to the next person directly, such as a three-way call. The loop closes when the receiving service confirms the client was helped.
Care Coordination and System Navigation continued
Digital navigation is part of the job
Appointments, results, refills and visits have moved online. This unit includes all 24 hours of Digital Health Navigator Pro: devices, getting connected, portals, telehealth, online safety and reliable information.
Barriers and follow-up
Rides, cost, childcare, language and work hours keep people from care. Medicaid usually covers rides to medical visits. Write down every next step with a date, and follow up until it is done.
Words CHWs Use
Organizing services so they fit together for the client.
Connecting a client directly to the next helper, for example on a three-way call.
A referral that is complete when the receiving service confirms the client was helped.
A secure website or app where patients see results, appointments and messages.
Ms. Begay's heart referral
Ms. Begay, 62, got a referral to a heart specialist three weeks ago. She has no appointment yet, no car and a prepaid phone that often runs out of minutes.
Your CHW steps
- Ask what she knows about the referral and what got in the way
- Call the specialist's office together to check the referral and book a visit
- Set up a ride through her Medicaid transportation benefit
- Help her turn on appointment reminders she can get on her phone
- Follow up after the visit to close the loop
In the Qwest, the steps are shuffled. Put them in the best order to help the client and earn your LIVE It coins.
Keep going: Care Coordination and System Navigation
The rest of this eBook — the scenario, unit check, Qwest lab, practicum log and answer key.
Get this eBook · $9.99All 12 eBooks + Ambassador membership · $49CHW Pro learners and Ambassadors: this series is included.Sign in to unlockCheck Your CHW Skills
- The referral form is sent
- The client is given a phone number
- The client says they will call
- The receiving service confirms the client was helped
- Connecting the client directly to the next helper
- Handing the client a brochure
- Mailing a letter
- Sending a fax
- The CHW
- The client and the care team
- The insurance company only
- The client's neighbor
- Unit 1
- Unit 12
- Unit 5, Care coordination and system navigation
- None of the units
- Drive them in your own car
- Skip the visit
- Tell them to reschedule
- Check their Medicaid transportation benefit
Answers are on page 11. In the Qwest this is the Boss Quiz — score 80% to earn the station badge.
Keep going: Care Coordination and System Navigation
The rest of this eBook — the scenario, unit check, Qwest lab, practicum log and answer key.
Get this eBook · $9.99All 12 eBooks + Ambassador membership · $49CHW Pro learners and Ambassadors: this series is included.Sign in to unlockStation 5 Qwest Lab
Every challenge uses this unit. Each one earns Live It coins and moves you toward the next CHW rank.
Keep going: Care Coordination and System Navigation
The rest of this eBook — the scenario, unit check, Qwest lab, practicum log and answer key.
Get this eBook · $9.99All 12 eBooks + Ambassador membership · $49CHW Pro learners and Ambassadors: this series is included.Sign in to unlockTeach It Forward
The fastest way to master a skill is to teach it. Your Share It challenge:
- Make a one-page list of who to call for what in your community and share it with your group.
- Use teach-back: ask them to explain it in their own words.
- Post what you learned (no client names) in your group or the Share It Studio to earn SHARE It coins.
Keep going: Care Coordination and System Navigation
The rest of this eBook — the scenario, unit check, Qwest lab, practicum log and answer key.
Get this eBook · $9.99All 12 eBooks + Ambassador membership · $49CHW Pro learners and Ambassadors: this series is included.Sign in to unlockRecord What Changed
Log one row per client goal during your practicum (up to 130 hours). A site supervisor initials each row. Record counts and minutes, never private health details.
| Date | Client goal (no names) | C3 role | Outcome | Minutes | Supervisor |
|---|---|---|---|---|---|
Outcome codes: SC screening completed · RM referral made · RC referral closed (loop confirmed) · AK appointment kept · CB coverage or benefits application submitted · HE health education delivered.
Keep going: Care Coordination and System Navigation
The rest of this eBook — the scenario, unit check, Qwest lab, practicum log and answer key.
Get this eBook · $9.99All 12 eBooks + Ambassador membership · $49CHW Pro learners and Ambassadors: this series is included.Sign in to unlockAnswer Key
- D. The receiving service confirms the client was helped — Closed loop = confirmed service.
- A. Connecting the client directly to the next helper — Make the connection together whenever you can.
- B. The client and the care team — You coordinate; the client and care team decide.
- C. Unit 5, Care coordination and system navigation — All 24 hours of DHN Pro are part of Unit 5.
- D. Check their Medicaid transportation benefit — Medicaid usually covers rides to medical visits. Check the plan.
Source: Community Health Worker Pro, Force for Health Academy (2026). CHW certification, scope and payment rules vary by state and change; check your state's current rules. CHW Pro is a training program, not a state certification.
Keep going: Care Coordination and System Navigation
The rest of this eBook — the scenario, unit check, Qwest lab, practicum log and answer key.
Get this eBook · $9.99All 12 eBooks + Ambassador membership · $49CHW Pro learners and Ambassadors: this series is included.Sign in to unlock12 units. 160 hours.
Each eBook pairs with a video lesson in the Force for Health Academy and a station in the CHW Qwest.
theforce.health/community-health-worker · FFH Virtual LibraryKeep going: Care Coordination and System Navigation
The rest of this eBook — the scenario, unit check, Qwest lab, practicum log and answer key.
Get this eBook · $9.99All 12 eBooks + Ambassador membership · $49CHW Pro learners and Ambassadors: this series is included.Sign in to unlock