Step 4: Care Coordination & Referral Management

Care coordination is the process of helping students and families move from screening results to completed dental care. It can help connect priority populations to the dental services they need by coordinating communication among families, schools, care coordinators, and dentalproviders.

Care Coordination

With dental care coordination, complementing a school-linked dental program can assist families to:

  • Understand the reason for referral
  • Understand the need and urgency to seek care
  • Navigate the dental healthcare system
  • Address logistical issues and barriers to accessing care
  • Obtain insurance and/or understand their covered services under Medi-Cal
  • Ensure continuity of care and/or adapt to changes or specialty care referral if indicated
  • Learn about optimal oral health behaviors for their children

If a student has Medi-Cal insurance or if you’re unsure if the family qualifies for Medi-Cal, use the dental care coordination referral form to ensure the child is connected to dental care.

Dental care coordinators

Dental care coordinators are personnel recruited to assist with dental care coordination need to be culturally sensitive, knowledgeable about the local community, ideally bilingual, and should be able to develop a rapport with the school administrators, families, and dental professionals. 

When recruiting personnel to assist with dental care coordination, programs can start by contacting their local office of education or local school district to identify if any existing school nurses are currently engaged in assisting the students' families.

In 2022, Medi-Cal added Community Health Worker (CHW) services as a benefit of the CalAIM ECM/ Community supports program.

CHWs provide preventive services to help Medi-Cal members better navigate and manage their chronic health conditions. These include: health education, health navigation, screenings/ assessments that do not require a license, individual support and advocacy, asthma preventive services, and violence preventive services. These services are provided under a Medi-Cal supervising provider, who submits claims for the CHW services.[1] CHW services can be provided on the topic of oral health to Medi-Cal members.

In 2024, Medi-Cal also added CHW services as a covered benefit to the Medi-Cal Dental program. With this addition, Medi-Cal Dental providers can become supervising providers and bill CHW oral health services to Medi-Cal Dental. As with the Medi-Cal benefit, the CHW services include dental care navigation (case management), and oral health education to individuals or groups.[2]

[1]Department of Health Care Services, Medi-Cal Providers. (2025, October). Community health worker (CHW) preventive services. California Health and Human Services Agency. https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/03BBA223-8762-4A94-A268-209510E15E37/chwprev.pdf?access_token=6UyVkRRfByXTZEWIh8j8QaYylPyP5ULO

[2]Department of Health Care Services. (2026). Medi-Cal Dental Community Health Workers. California Health and Human Services Agency.https://www.dhcs.ca.gov/services/Pages/Dental-Community-Health-Workers.aspx

Resources for care coordination

Care coordinators should be provided with the necessary training and resources to coordinate dental care for students following a dental screening. Here are some helpful training topics:

 

Communication strategies

When presented with a situation where the children/parents/guardians are not inclined to access dental care, care coordinators can utilize the following steps to promote the utilization of dental care as well as good home care. The following strategy is adopted from the 5Rs approach to tobacco cessation.

The 5 Rs Approach to better communication in Care Coordination
RelevanceEncourage the child/parent/guardian by stating why routine dental care is relevant to them. Be as specific as possible including how it may affect school attendance and the need for advanced care.
RisksAsk the child/parent/guardian to identify potential negative consequences of their lack of routine dental care, including acute and long-term risks.
RewardsAsk the child/parent/guardian to identify potential benefits, such as improved health, self-perception, and cost savings.
RoadblocksAsk the child/parent/guardian to identify barriers (e.g., fear of dentist, transportation, language, cost, etc.) and provide assistance and resources to address them.
RepetitionRepeat the motivational intervention every time the child/parent/guardian is seen.

*Note: The target for intervention is often the parent/guardian and not the child patient.

Referral Management Systems

Using an electronic referral management system will allow:

  • Care coordinators to send referrals directly to dental providers
  • Assistance with scheduling children’s dental appointments
  • Efficient communication with parents/guardians and dental providers
  • Tracking the success of referrals (i.e., what happens after a referral is given)
  • Data metrics to communicate findings to school administrators, stakeholders, and funding agencies
  • Development of quality improvement strategies

COHTAC Share & Learn: How to Plan for Creating Community-Clinical Linkages

Examples of referral management systems being used by LOHPs