Promising Strategies for Community Service Navigation
Lessons from Health Quality Innovators
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Associated Project
Accountable Health Communities: Identifying and Addressing Social Determinants of Health
Prepared for:
U.S. Department of Health and Human Services
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services, Center for Medicare & Medicaid Innovation
Key Findings
- Contracting with an organization experienced in community health worker initiatives facilitates training and oversight of navigators.
- Hiring navigators with strong interpersonal skills and ties to the community helps build rapport to engage patients.
- Training navigators in motivational interviewing equips them to focus on a patient’s individual strengths and self-efficacy, which helps them develop an action plan that incorporates the patient’s goals.
This case study describes key strategies that Health Quality Innovators, an AHC Model awardee, used to conduct community service navigation as part of the Accountable Health Communities Model. The organization used both internal and external navigators to help connect high-risk Medicare and Medicaid beneficiaries with community services to address their health-related social needs. The case study highlights navigator training, outlines the steps in the navigation process, shares common challenges, and offers promising strategies for community service navigation.
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