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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.

1. 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.

2. 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. 

3. 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.

4. 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.

5. Measure CHI Impact and 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.

6. 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.

Codes

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.

HCPCS 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.

Frequently Asked Questions About Community Health Integration

1. Who can receive CHI services?

Patients are eligible if they:  
 

  • 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

2. 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  

3. Can CHI be delivered virtually?

Yes! CHI services can be provided via:  
 

  • Phone  

  • Video call  

  • In-person  

  • Hybrid models  
     

As long as documentation supports the interaction and purpose. 

4. 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.

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