Integrated Care Coordinator Position

Objective: Increase enrollment in federal and Wisconsin’s health programs by doing outreach and education and by providing accessibility and advocating for patients. To be more proactive in screening patients who are uninsured and determining eligibility for health assistance programs.

Description: The Gerald L. Ignacio Indian Health Center-Milwaukee (GIIHC) needed to come up with a solution on how to increase access to Wisconsin’s health programs. They have concluded that some of the barriers their patients face are lack of education regarding health insurance, accessibility (e.g. access to computers or phones), and someone to help them through the health care process. In addition, while screening patients for state insurance program eligibility and assisting them in making appointments for their referrals, GIIHC has noticed that patients often don’t know what kind of insurance they have and what is in their network. Members of federally recognized tribes, as well as descendants and non-natives who reside in the Milwaukee metropolitan area (primarily those who are under-insured and uninsured), are the main target of this activity. GIIHC is one of the 16 sliding-fee-scale health clinics in Milwaukee that serves the uninsured.

GIIHC implemented the role of Integrated Care Coordinator for outreach and enrollment. The responsibility of this role is to improve access to care by assisting patients with referrals, signing up for federal and state insurance, and promoting patient advocacy. The coordinator also educates patients on how to access community resources and acts as a liaison with departments, specialists and other agencies.

When the healthcare provider sees a patient who doesn’t have insurance or has limited resources, the provider calls the integrated care coordinator into the exam room to screen the patient.

Population of Focus: American Indian or Alaska Native, Adolescents, Adults, Children, Elderly, Limited English Proficient, Transition aged, Women.

Setting: Community health center, Primary care facility, Urban

Level of Intervention: Family, Individual

Resources/Qualifications Needed: Policies and procedures were put into place for this position that would be important to have for replication. Outreach brochures were also developed.

Partners: State, state tribes, tribal benefit specialists and other community health centers


Jacob Nowak
Integrated Care Coordinator
Gerald L. Ignace Indian Health Center, Inc.
1711 South 11th Street Milwaukee, WI 53204|
Phone: (414)383.9526 Fax: (414)649.2711