Rewrite the strategy for the paragraph -Engage relevant personnel. A care navigator, care manager, or other team member might be best suited to identify community resources. Maximize use of technology. If your electronic health record (EHR) system has the capability to do referrals to community-based organizations, that is likely the best way to ensure that patients follow through. (Also see Chapter 3: Follow-up and Care Coordination.) Keep documentation on available local resources