Care Coordination and Resource Navigation
What to know
Care coordination is the deliberate organization of care across providers, settings, and time. Faith community nurses often serve as the bridge: medication reconciliation, referral, appointment support, transportation planning, and follow-up after hospitalization. Screen for social determinants such as housing, food, transport, cost, caregiver capacity, and health literacy. Know the difference between a referral (a handoff) and navigation (active help getting there). Use closed-loop communication: confirm the client connected, the receiving agency acted, and the plan is understood. Protect privacy under HIPAA and congregational norms; share only the minimum necessary with consent.
Traps
- Making a referral and assuming the client followed up.
- Overlooking practical barriers and labeling the client "noncompliant."
- Duplicating a service a partner already provides.
- Discussing a client's health in a congregational setting without permission.
- Documenting the coordination but not the outcome.
Worked example
A client discharged after heart failure is told to see a cardiologist in two weeks. The nurse confirms the appointment exists, checks transportation, reconciles medications against the discharge list, and calls three days later to verify attendance. When the ride falls through, she connects the client to a transport voucher. Rule of thumb: no referral without a loop. Confirm, support, and follow up.