• Acts as a bridge between health care providers, community-based providers, and individuals in the community • Understands experiences, socioeconomic needs, language, and/or culture of the communities served • Spends time outreaching, providing health education, and helping patients navigate health systems • Identifies barriers to care and assists in changing service delivery to improve patient and community health • Builds individual and community capacity by increasing health knowledge and self-sufficiency through outreach, community education, social support, and advocacy • Serves as a liaison between communities and health care systems/agencies • Provides guidance and social assistance to patients and the entire care team • Enhances patients' ability to effectively communicate with healthcare providers and care team members • Provides culturally and linguistically appropriate health education using evidence-based sources • Advocates on behalf of patients, families, caregivers, and communities to obtain needed care and/or resources • Informs health care providers and care team members of barriers and challenges limiting patients' abilities • Establishes and maintains collaborative relationships with community-based organizations and across the care continuum