Community Health Integration (CHI) Services

Implementation

Organizations interested in providing CHI services should:

• Partner with a Medicare-enrolled physician or other eligible billing practitioner.
• Define the role of CHWs or CHRs within the care team.
• Develop workflows for referrals, documentation, communication, and supervision.
• Create processes to identify eligible Medicare beneficiaries.
• Establish documentation practices that support Medicare billing requirements.
• Ensure staff understand supervision, consent, and care plan requirements.

Implementation may look different depending on whether services are provided in a hospital, clinic, tribal health program, Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or community-based organization.

Principal Illness Navigation (PIN) Services 

Implementation

Organizations implementing PIN services should:

• Identify Medicare beneficiaries who have qualifying chronic or serious health conditions.
• Establish referral pathways from healthcare providers.
• Define the CHW or CHR role within the interdisciplinary care team.
• Develop documentation workflows that capture navigation activities.
• Create individualized care plans in collaboration with the supervising practitioner.
• Ensure staff receive training on Medicare documentation and billing requirements.

Organizations serving American Indian communities may find that CHRs are well-positioned to provide culturally appropriate navigation services while working closely with healthcare providers.