Connects patients to community resources including, but not limited to, locating support services for housing, food, clothing, education, life skills classes and employment; Helps patients learn where to find community resources, schedule appointments with social services agencies and complete applications for benefits /programs for which they may be eligible; Assists patients in accessing primary care services including, but not limited to, establishing a medical home, providing instruction on appropriate use of the medical home, and overcoming barriers to obtaining needed clinical care and/or social services; Provides support and advocacy during the patient's initial medical visit and/or when necessary to assure patient's needs are understood and communicated; Coordinates and monitors services, including comprehensive tracking of patients' compliance in relation to care plan objectives; Coaches patients in effective management of their chronic health conditions and self-care; Motivates patients to be active and engaged participants in their health and overall well-being; Documents all encounters and contacts made on behalf of patients in an effective manner in the appropriate patient electronic record, or elsewhere, as directed. Establishes trusting relationships with patients and their families while providing general support and encouragement; Communicates to FCCH patients the value of having a CHW supporting them and the impact such support may have on their health and wellbeing; Helps patients identify socio-economic issues that affect their overall health and develop health/social management plans and goals; Assists patients in understanding the services, plans and instructions of the health insurance program in which they are enrolled, or their options if uninsured; Communicates with Managed Care Organizations about interventions provided to their members seeking FCCH services; Facilitates communication and coordinates services between providers and patients.