Identifying and managing the care of patients at high risk for readmission or poorly managed health has always been about doing the right thing for the patient. But keeping patients out of the hospital punishes health systems unless financial incentives are aligned in risk-based payment models that support those good intentions. The Affordable Care Act (ACA) and other federal and private initiatives are pressing changes to move to coordinated, community-based systems of ‘whole person’ care. Health systems have achieved remarkable success by employing case managers and support staff to identify opportunities, make connections, close gaps, and troubleshoot problems. Many of the critical roles in this area—helping patients access care, navigate the system and participate in their own wellness—can be supported by specially-educated and trained, culturally-competent, non-licensed clinical staff. Through the COPE Health Solutions’ certification program for non-clinically licensed (and licensed) individuals, we provide customized development, training and thoughtful execution for care coordination and patient ambassador services that improve care delivery across a fragmented and complex health care system.