Community Health Integration (CHI) Services

Overview

Community Health Integration (CHI) services are designed for Medicare beneficiaries who have one or more unmet social needs that significantly interfere with their ability to follow a treatment plan or achieve health goals.

CHI services focus on identifying barriers to care and connecting individuals with the resources and supports needed to improve health outcomes. Common activities performed by CHWs or CHRs may include:

• Assessing health-related social needs
• Helping individuals access community resources
• Coordinating services among healthcare providers and community organizations
• Assisting with care transitions
• Supporting adherence to treatment plans
• Helping resolve barriers such as transportation, food access, housing instability, or other social needs
• Documenting services provided and communicating with the supervising healthcare team

CHI services are furnished under the direction of the billing practitioner and as part of an individualized care plan.

Principal Illness Navigation (PIN) Services 

Overview

Principal Illness Navigation (PIN) services help Medicare beneficiaries with one or more serious, high-risk chronic conditions successfully navigate their healthcare journey.

PIN services recognize that individuals with complex medical conditions often benefit from ongoing navigation, education, coordination, and support provided by trusted members of the care team, including CHWs and CHRs.

Activities may include:

• Helping individuals understand their diagnosis and treatment plan
• Coordinating appointments and follow-up care
• Facilitating communication among providers
• Connecting beneficiaries with community resources
• Addressing barriers that interfere with disease management
• Supporting self-management goals
• Providing culturally responsive and person-centered navigation
• Documenting services and communicating with the healthcare team

PIN services are intended to improve care coordination, reduce fragmentation, and support successful management of serious chronic conditions.

Considerations for CHW and CHR Programs in South Dakota

CHI and PIN services offer new opportunities for organizations to integrate CHWs and CHRs into interdisciplinary care teams while supporting sustainable funding for services provided to Medicare beneficiaries.

Successful implementation requires thoughtful planning, including:

• Strong partnerships with Medicare-enrolled practitioners
• Clearly defined CHW or CHR roles and responsibilities
• Standardized documentation processes
• Staff training on Medicare requirements
• Ongoing communication between clinical and community-based partners
• Quality assurance and compliance monitoring

Programs interested in implementing CHI or PIN services should evaluate their current workflows, staffing, documentation systems, and partnerships to determine their readiness for Medicare reimbursement.