Case Study-Promising Strategies for Community Service Navigation: Lessons from Health Quality Innovators

Publication Year: 2019
Patient Need Addressed: Care Coordination/Management
Population Focus: Dual eligible, Medicaid beneficiaries
Intervention Type: Best practices
Type of Literature: Grey

This case study describes key strategies that Health Quality Innovators, an Alignment Track bridge organization, developed to conduct community service navigation as part of the Accountable Health Communities Model. The purpose of this case study is to highlight a successful navigation approach from one bridge organization that could help inform practice at other Accountable Health Communities Model sites or in the healthcare community. Accountable Health Communities bridge organizations are using multiple strategies to deliver community service navigation, each with different strengths, challenges, and promising practices. The navigation approach discussed in this case study works in the Health Quality Innovators community and outcomes may vary at other sites. This case study is not part of the formal Accountable Health Communities Model evaluation

Insights Results


  • Navigators reported that the population is generally hard to reach and tends not to respond to outreach
  • Beneficiaries’ phone numbers frequently change or get disconnected, and they may not respond to follow-up calls
  • The Accountable Health Communities Data System does not include features for documenting certain details related to navigation such as tracking contacts and follow-ups, documenting qualitative encounter notes, or sorting beneficiaries by follow-up date
  • A strategy that combines calling beneficiaries at different times and on different days, texting them, sending emails, and/or mailing letters maximizes a navigator’s chances of connecting with beneficiaries
  • When navigators use the initial call to explain the program, manage the beneficiary’s expectations, and gather information about the beneficiary’s health-related social needs (or conduct the personal interview), they build a relationship with the beneficiary, which deepens their understanding of the beneficiary’s needs and promotes beneficiary engagement in navigation
  • Documenting beneficiary outreach, contact, and follow-up activities is essential to staying current on each beneficiary’s status and needs, which facilitates the delivery of the best possible navigation services
  • Navigators try to connect with beneficiaries within two days of when the beneficiaries received community referral summaries; however, it often takes longer. Navigators have found that calling and leaving voice messages at different times and on different days helps them to connect with beneficiaries
  • External navigators have found that sending text messages can help them to reach beneficiaries whose minutes are limited by their cell phone plans. Internal navigators mail follow-up letters that include their contact information to beneficiaries who have not responded after three outreach attempts. Both external and internal navigators rely on a SharePoint tracker to document outreach attempts and contact with beneficiaries. Navigators have found the tracker to be essential for monitoring each beneficiary’s status, including when he or she was last contacted and when the next outreach attempt is due
  • Hire navigators with strong interpersonal skills and ties to the community. These qualities help navigators to understand the experience of beneficiaries, build rapport with them, and accommodate their needs
  • Meet in person. For at least some beneficiaries, meeting in person rather than by phone is a better way for them to participate in navigation
  • Use motivational interviewing. A disarming and empathic approach to interviewing that focuses on individual strengths and self-efficacy, and that incorporates beneficiaries’ goals into the natural flow of conversation enables navigators to gather information for the action plan while making the beneficiary feel comfortable
  • Develop secure and reliable processes for information sharing. The use of shared networks supports the navigator’s efforts to share beneficiary-level navigation information (such as completed action plans) with clinical providers at clinical delivery sites
  • Establish data-driven quality improvement. By regularly monitoring navigation activities and collecting feedback from staff, bridge organizations can readily identify and address challenges and improve processes
    Future considerations
  • Institute for Public Health Innovation (IPHI) is working to identify which subsets of the beneficiary population are best served by each approach. Less complex cases, such as beneficiaries with one health-related social need, are better candidates for phone-based interviews than those with several health-related social needs
  • The bridge organization and IPHI leaders are interested in connecting with other bridge organizations that use phone interviewing in order to share promising strategies for offering high-quality navigation services