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

Publication Year: 2019
Patient Need Addressed: Care Coordination/Management, Patient satisfaction/engagement
Population Focus: Medicaid beneficiaries
Intervention Type: Best practices, Partnership, Staff design and care management
Type of Literature: Grey

The Accountable Health Communities (AHC) Model addresses a critical gap between clinical care and community services in the current healthcare delivery system by testing whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries through screening, referral, and community navigation services will impact healthcare costs and reduce healthcare utilization.

Insights Results

Overview of article

  • 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 model provides support to community bridge organizations to test promising service delivery approaches aimed at linking beneficiaries with community services that may address their health related social needs
  • The bridge organization has developed several promising practices for community service navigation that may be useful: 1) Hire navigators with strong interpersonal skills and ties to the community; 2) Use multiple methods to reach beneficiaries; 3) Use the initial contact strategically; 4) Meet in person; 5) Use Motivational interviewing; 6) Document navigation activities; 7) Develop secure and reliable processes for information sharing; and 8) Establish data-driven quality improvement

Key takeaways/implications

  • Future considerations: The bridge organization and Institute for Public Health Innovation (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. For the bridge organization and its partners, this navigation approach has shown some early success, but further research would be needed to make a determination on best practice