Solutions
Social Care Providers & Community Based Organizations
CHI and PIN Medicare billing support, interoperability with health systems and HIEs, and the data exchange infrastructure to improve service access and delivery for the clients who need it most.
A Multisector, Diverse Ecosystem
Social care providers and community-based organizations serve a diverse set of clients — many experiencing poverty, homelessness, developmental disabilities, childhood and adult traumas, or working as older adults to receive care at home while managing multiple transitions in care.
While we have made some effort to call out the needs of just a few of these sectors, it’s important to acknowledge the limitations of putting large, complex communities into the broad category “Social Care Providers / Community Based Organizations.” Our purpose in doing so is to work in partnership with these organizations to identify the most important opportunities for data exchange that can improve service access and delivery — especially when that process touches healthcare providers and will need to interact with healthcare data standards.
Continuums of Care, Homeless Shelters, and Housing Service Providers
Continuums of Care (CoC), homeless shelters, and housing service providers face significant challenges in coordinating services for clients who often have multiple and complex needs — including poverty, mental health issues, substance abuse, and chronic health conditions.
These organizations typically operate with limited resources while navigating a complex system of government regulations and funding streams. Most critically, they struggle to coordinate care with other providers because services and data continue to operate in silos — making it difficult to ensure clients receive the comprehensive support they need.
Fragmented Data, Fragmented Care
When housing, clinical, and social service records live in separate systems, no one on the care team has the full picture. Navigator360 creates a unified person record that follows the client across every provider.
Complex Funding Navigation
CoC programs, HUD programs, Medicaid, and local funding streams each have different eligibility rules and documentation requirements. Navigator360 screens for all of them in a single workflow.
Closing the Referral Loop
A referral that disappears is a client who didn't get help. Closed-loop referral tracking ensures every handoff between housing, health, and social service providers is documented and followed up.
Aging and Disability Networks
Area Agencies on Aging (AAAs) and Aging and Disability Resource Centers (ADRCs) face a distinct set of challenges in fulfilling their mission of supporting older adults and individuals with disabilities. AAAs and ADRCs connect clients with a wide range of services across medical, social, and government sectors — but these sectors often operate on separate data systems and communication channels, making it difficult to ensure a smooth and coordinated flow of care.
Complexities in Care Coordination & Cross-Sector Interoperability
AAAs and ADRCs connect clients with services across medical, social, and government sectors. But these sectors often maintain separate data systems and communication channels, making coordinated care difficult to achieve and impossible to document consistently.
Limited Resources Against Rising Demand
Funding for AAAs and ADRCs often doesn't match the growing demand driven by an aging population. This limits staffing capacity, program depth, and the ability to invest in the technology infrastructure that modern care coordination requires.
Reaching Underserved Populations
Outreach efforts may not resonate with all communities — particularly those with cultural or language barriers. This creates gaps in service access for the most vulnerable populations that AAAs and ADRCs are specifically mandated to serve.
Navigating Eligibility Complexity
Programs offered by AAAs and ADRCs often have specific and overlapping eligibility requirements. This complexity overwhelms clients and their families, leading to delays and missed opportunities for critical assistance.
Keeping Information Current
The landscape of available services and resources changes constantly. Maintaining accurate, comprehensive, and up-to-date information is a persistent operational challenge — one that directly affects whether clients find the right service at the right time.
AAAs and ADRCs face challenges in coordinating care effectively because systems across medical, social, and government sectors often don’t communicate seamlessly. Limited funding hinders their ability to meet rising demands for services. Outreach to underserved populations can be difficult, and navigating complex eligibility requirements creates barriers to accessing important services. Keeping up-to-date on the ever-changing landscape of resources is another significant challenge — one that Navigator360 is built to address.
What Navigator360 Delivers
CHI & PIN Medicare Billing
Community Health Integration (CHI) and Principal Illness Navigation (PIN) billing support built into Navigator360. Documentation infrastructure that meets CMS standards — generated automatically as you work.
Cross-Sector Data Exchange
FHIR-native data exchange with health systems, HIEs, and government agencies. Your work becomes part of the clinical and administrative record — visible to the full care team and documentable for billing and compliance.
Eligibility Screening Across 300+ Programs
Screen clients for 300+ government programs in a single workflow — including Medicaid, SNAP, housing assistance, LIHEAP, WIC, and more. One intake. Every benefit the client qualifies for.
Closed-Loop Referral Tracking
Send and receive referrals with health systems, managed care organizations, and government agencies. Every referral tracked from initiation to outcome. Nothing falls through without a record.
26+ Language Support
Serve clients in their preferred language. Navigator360 supports 26+ languages, helping organizations reach the underserved populations that most need access to benefits and services.
Always-Current Resource Directory
Access to a national crowdsourced directory of 276,000+ health and human service organizations — continuously updated so your team always has accurate, current information when clients need a referral.
See Navigator360 for Social Care Providers
We partner with organizations at every stage — from single-site CBOs to statewide aging networks — to identify the data exchange opportunities that improve outcomes for the clients you serve.
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