Community-Based Healthcare Navigation – Project 2.c.i


Health literacy, community values, language barriers, and lack of engagement with community health care services can result in avoidable use of hospital services. Those patients who do not understand how to access and properly use the health care system cannot be expected to use it effectively. A health navigation service has been created to help assist these patients access the system effectively and properly by providing bridge support until the patient has the confidence to manage their own health.

Care Compass Network’s Goals

  • Collaborate innovatively with Health Care Systems and Community-based Organizations to address the social determinates of health and ensure patients have a warm hand-off to community navigators.
  • Develop a 2-1-1 Community Resource Guide to ensure all who work with patients can identify their needs, and refer them appropriately to organizations in the community.
  • Strengthen the continuum of care in both the Health Care Systems and Community-based Organizations across Care Compass Network’s nine-county region.

Who is Eligible to Participate in the Project?

Any Hospital or Community-based Organization that provides a service(s) to Medicaid members with Care Compass Network’s nine-county region.


Latest News & Updates

Transformation Grant Program: Next Steps – June 26, 2018

The Transformation Grant workgroup is developing a ‘what is the value’ document to provide information on the benefits of using a Community Health Worker (CHW) to outreach low-and non-utilizers and get them engaged or re-engaged with their primary care provider. A recent report from Baltimore, MD analyzed six innovation funding projects. Of those six projects, only those that used Community Health Workers showed a reduction in costs per beneficiary per quarter. Click here to view the full report.

Transformation Grant Program: Making Strides to Outreach Medicaid Members – February 21, 2018

In October of last year, Care Compass Network announced a total of 7 community-based organizations that were awarded funds from the Community-based Navigation Transformation Grant program. The purpose of this program is to support community organizations in their efforts to outreach and engage Low to Non-Utilizers within the Medicaid population that are located throughout CCN’s nine-county region. […] Read More

Important Notice – Quarterly Reporting due by October 25th – October 18, 2017

For Partners Contracted to do Project Work: With the first 6 months of DSRIP Year 3 complete, CCN must submit the patient engagement reporting data to the DSRIP Independent Assessor in order to earn performance dollars tied to speed and scale. If you have not submitted your date for April 1st – September 30th 2017, please submit your activity by October 25th. All speed and scale reports or any document (could include a screenshot, email, word document, excel file, etc) that includes PHI should be submitted via the sFTP site. For additional information on the sFTP site, please click here to view the CCN sFTP Guide.

Care Compass Network Supports Partner Organizations Through IT Funding Opportunities – August 24, 2017

Care Compass Network (CCN) can help support partner organizations through approved IT funding opportunities. Currently, programs are in place to assist partners with new implementations of EMR/ EHR systems and to provide funding to accommodate […] Read More

Community-based Navigation Transformation Model Grant Webinar – August 4, 2017

Emily Balmer, Care Compass Project Manager discusses the Project 2ci Community-based Navigation Transformation Model Grant. The intent of this webinar will be to discuss the grant and frequently asked questions that Care Compass Network is receiving. […] Watch Now

New Funding Opportunity for Tier 1 and Tier 2 Community-based Organizations – July 19, 2017

Care Compass Network (CCN) is exited to announce a new funding opportunity through the 2ci Community Navigation Project for Tier 1 and Tier 2 Community-based Organizations in our PPS. CCN has prepared three downloadable documents that includes additional information on the new funding opportunity through CCN. The documents are: Request for Application, Scorecard for the Application, FAQ on the Application and the 2ci Navigation Project.

Community Navigation CBO Engagement Model Webinar – May 12, 2017

Emily Balmer, Project Manager at Care Compass discusses the CBO Engagement Model for the Community Based Navigation (2ci) Project and the project-specific items of the Phase II Appendix C […] Watch Now

Care Compass Network Develops 2-1-1 Community Resource Guide – December 21, 2016

Everyone knows to dial 9-1-1 in case of an emergency, but there’s another number that you might not have programmed into your member. 2-1-1 is a free number people can call to get non-emergent information and assistance. After dialing 2-1-1, a live person […] Read More