Community Health Integration for Providers
Clinii’s Community Health Integration (CHI) program helps healthcare providers address social determinants of health (SDOH) by connecting patients to local support services, care coordinators, and community-based preventive health programs. This integrated approach promotes equity, improves outcomes, and strengthens community partnerships.
What is Community Health Integration?
Community Health Integration (CHI) involves integrating healthcare services within community settings to enhance access, improve health outcomes, and address social determinants of health (SDOH) by linking individuals with local resources and support. CHI services are reimbursable under HCPCS codes G0019 and G0022 and can be delivered virtually, in person, or through hybrid models.
Primary Aims of Community Health Integration
Address Social Determinants of Health (SDOH) With CHI
CHI is a strategic approach to addressing SDOH—factors like housing, food access, education, and transportation—that significantly influence health outcomes. Traditional clinical care alone cannot fully address these external variables, which often drive disparities and chronic health burdens. By embedding CHI into care delivery, healthcare systems can extend their reach beyond clinic walls, systematically identifying and responding to patients’ social needs. This integrated model empowers providers to adopt a more holistic, equity-centered approach to health promotion, ultimately improving both individual and community-level outcomes.
Improve Health Equity Through CHI
Equitable access to care remains a persistent challenge in underserved communities. CHI serves as a bridge between clinical systems and community-based support services, fostering pathways for patients to access resources they might otherwise be unaware of or unable to reach. Through systematic screening, referral, and follow-up mechanisms, CHI initiatives can ensure that no patient falls through the cracks—particularly those with complex needs or barriers related to income, language, housing, or transportation.
Use Care Coordinators to Strengthen CHI
At the core of effective CHI programs is the integration of care coordinators who function as liaisons between patients, providers, and community partners. These professionals assess individual needs, guide patients through the navigation of services, and ensure follow-through on referrals. Their involvement not only reduces fragmentation in care but also builds trust with patients, improving adherence to medical and social care plans.
Support Preventive Health With Community Integration
Preventive health initiatives—such as vaccination drives, health screenings, and education campaigns—gain traction and impact when integrated into community-based frameworks. CHI models amplify these efforts by embedding them within trusted local institutions and aligning them with culturally appropriate outreach. This localized approach enhances community participation, promotes early intervention, and fosters long-term engagement with the healthcare system, ultimately reducing the burden on acute care services.
Measure CHI Impact & Inform Systemic Change
Successful CHI programs are rooted in data-informed strategies. Healthcare organizations must track the effectiveness of community linkages, follow-up outcomes, and improvements in SDOH metrics. These insights can inform policy, resource allocation, and program design, ensuring sustained improvements in population health. Moreover, longitudinal data allows stakeholders to identify trends, uncover service gaps, and advocate for systemic reforms that advance health equity on a broader scale.
Power CHI Workflows With Clinii’s Platform
Clinii’s CHI platform offers a powerful technology-enabled approach to implementing and scaling community health initiatives. By integrating with clinical systems, Clinii connects healthcare providers with local resource networks, care coordinators, and preventive health programs through a centralized, easy-to-use platform. This streamlines workflows, automates referrals, and enables real-time tracking of patient progress and social needs resolution. With Clinii, healthcare professionals are equipped to take a proactive, data-driven stance on community engagement, ultimately improving outcomes across diverse populations.
Staff/Social Worker
HCPCS G0019
Reimburses for 60-minute sessions conducted by clinical staff focusing on integrating community health services. This code supports complex case management, enhancing community resource coordination and patient support.
Learn MoreHCPCS G0022
Provides reimbursement for 30-minute sessions aimed at CHI. This code is used for shorter, focused interactions that address patient needs through community resources and brief case management activities.
Learn MoreWhy Clinii is Your Trusted Partner
AI-powered platform Nationwide, fully compliant
care plan enhancement Proven results: 300%+ care
plan usage, 92% claim approval Seamless EHR
integration Key Benefits
Higher quality of care
Reduced hospital readmissions
Medicare reimbursement
EHR integration and automated reporting
Frequently Asked Questions About Community Health Integration
Who can receive CHI services?
Patients are eligible if they:
- Are under the care of a Medicare-enrolled provider, and
- Have identified social risk factors that negatively affect their health (e.g., housing insecurity, lack of transportation, and
- Receive services under a primary care setting or equivalent
Who can provide CHI services?
CHI services are provided by trained or certified auxiliary personnel, such as:
- Community Health Workers
- Social workers
- Peer support specialists
- Care coordinators
Can CHI be delivered virtually?
Yes! CHI services can be provided via:
- Phone
- Video call
- In-person
- Hybrid models
How does Community Health Integration improve patient outcomes?
CHI helps providers address the non-clinical factors that affect health—like housing, food access, and transportation—by connecting patients to community resources and care coordinators. This leads to earlier interventions, better adherence to care plans, and reduced reliance on emergency services.
Other Programs
APCM
Advanced Primary Care Management (APCM)
Clinii’s Advanced Primary Care Management (APCM) services provide healthcare teams with the tools and support needed to deliver high-quality, patient-centered care.
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Annual Wellness Visit (AWV)
Clinii’s Annual Wellness Visit (AWV) program helps providers deliver preventive care assessments, identify health risks early, and improve Medicare reimbursement efficiency.
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Behavioral Health Integration (BHI)
Clinii’s Behavioral Health Integration (BHI) services provide seamless collaboration between primary care providers and mental health specialists, improving access and driving better overall health outcomes.
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Chronic Care Management (CCM)
Clinii’s Chronic Care Management (CCM) solutions enable providers to deliver personalized remote support, track patient progress, and maximize CMS reimbursements—all while reducing hospital readmissions.
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Principal Care Management (PCM)
For patients managing a single high-risk chronic condition, Clinii’s Principal Care Management (PCM) program provides targeted support, care coordination, and specialist oversight.
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Remote Physiological Monitoring (RPM)
Clinii’s Remote Physiological Monitoring (RPM) solutions empower providers to track real-time patient vitals, detect early health risks, and reduce hospital visits through continuous remote monitoring.
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Remote Therapeutic Monitoring (RTM)
Clinii’s Remote Therapeutic Monitoring (RTM) solutions enable providers to track medication adherence, respiratory health, musculoskeletal recovery, and behavioral therapy progress remotely.
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Transitional Care Management (TCM)
Clinii’s Transitional Care Management (TCM) services support providers in coordinating post-discharge care, optimizing Medicare reimbursements, and improving patient recovery outcomes.
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Value-Based Care (VBC)
Clinii’s Value-Based Care (VBC) solutions help providers transition from fee-for-service to outcome-driven reimbursement models.
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