Program · G0019 / G0022
Community Health Integration (CHI)
Support for the social needs that block the care plan—housing, food, transportation, benefits, and caregiver gaps—handled by our navigators instead of your front desk.
What it is
Community Health Integration is a Medicare service for patients whose social needs are getting in the way of the treatment plan their clinician has set.
SageAlly's navigators identify those barriers, connect patients to community resources, follow up until the need is resolved, and document the work for your provider's review.
Services are billed by your practice and furnished by SageAlly's care team under your clinicians' supervision.
Which patients it's for
- Patients missing appointments because they lack transportation
- Patients facing food insecurity or special dietary needs
- Patients with unstable housing
- Patients who need help applying for benefits
- Patients without enough caregiver support at home
- Patients whose social needs your clinicians flag at the initiating visit
What our navigators do each month
- Identify the social needs blocking the plan of care
- Connect patients to food, housing, and transportation resources
- Help with benefits and insurance applications
- Find caregiver and in-home support
- Follow up until each need is resolved
- Log time and activity for every patient interaction
What your practice does
- Perform the initiating visit and identify social needs
- Obtain and document patient consent
- Provide general supervision
- Review and sign monthly navigation notes
- Submit claims under your NPI
Clinical questions are always routed back to your practice.
Documentation we provide
- Time-tracked monthly notes per patient
- The social needs addressed and the resources connected
- A monthly sign-off packet for your provider
- A billing summary for your biller and a monthly program report
PIN and CHI together
CHI often pairs with PIN for patients with a serious illness and social barriers. We can support both for the same patient, with time tracked separately per program, per CMS rules.
Compare the programs: Principal Illness Navigation and Community Health Integration.
Frequently asked questions
Let's see if your patient panel is a fit.
A short call is the fastest way to find out. Tell us about your practice and we'll follow up.
Patient or family member?
For Patients & Families