Understanding the Medicare Physician Fee Schedule Billing Codes For: Community Health Integration, Principal Illness Navigation, and Principal Illness Navigation-Peer Support Services

This toolkit details options for implementing recently introduced Medicare services that address members’ health-related social needs.

Implementation Tool

March 2024

The Return on Investment (ROI) Calculator for Healthcare Partnerships to Address Social Needs

This tool can support health care and community-based organizations in building sustainable cross-sector partnerships.

Implementation Tool

October 2023

Community Health Worker Model Best Practice Toolkit for Designing, Implementing and Showing Impact

Toolkit provides best practices and practical tools for designing, implementing, and evaluating the impact of community health workers.

Implementation Tool

March 2023

Addressing Social Isolation and Loneliness Among Older Dually Eligible Individuals

Toolkit offers recommendations and examples for screening and interventions that support social connectivity of older adults.

Implementation Tool

November 2022

Reimbursement Strategies for Employers of Community Health Workers

This toolkit supports organizations to bill for community health workers/promotores interventions.

Implementation Tool

October 2022

Guide to Evidence for Health-Related Social Needs Interventions: 2022 Update

Summarizes evidence on costs of health-related social needs interventions and their impact on utilization and cost of care to inform ROI Calculator users.

Implementation Tool

September 2022

Hunger Vital Signs Screening Implementation Guide

Guide offers implementation recommendations for introducing food insecurity screenings in clinical settings, including workflow and staffing considerations.

Implementation Tool

September 2022

Food Bank-Health Care Partnerships

Guidance and tools for food banks to partner with health care organizations to address food insecurity and improve health outcomes.

Implementation Tool

January 2022

Leveraging Medicaid Accountable Care Organizations to Address Health Equity: Examples from States

Tool shares strategies for states to use Medicaid accountable care organization agreements to promote health equity.

Implementation Tool

May 2021

Rural Community Paramedicine Toolkit

Toolkit offers health care stakeholders in rural areas with practical information to support the design, implementation, and evaluation of community paramedicine programs.

Implementation Tool

June 2020

Food Banks as Partners in Health Promotion: Navigating HIPAA

Food banks can use this tool to learn approaches to information-sharing for health care partnerships and interventions.

Implementation Tool

June 2020

HOUSED BEDS: A Clinical Tool for Taking a History on an Unsheltered Homeless Patient

A tool helps providers capture essential information when interviewing people experiencing unsheltered homelessness to support effective treatment planning.

Implementation Tool

July 2019

A Turning Point in Medicare Policy: Guiding Principles for New Flexibility Under Special Supplemental Benefits for the Chronically Ill

How to implement the new Medicare benefits.

Implementation Tool

July 2019

Addressing Health Equity through Health and Housing Partnerships

Strategies for health centers and supportive housing providers to advance health equity by partnering to provide person-centered care.

Implementation Tool

May 2019

The ROI Calculator for Partnerships to Address the Social Determinants of Health

A web-based financial tool that helps navigate partnerships between health care organizations and social service organizations.

Implementation Tool

August 2018

Overview of Segmentation of High-Need, High-Cost Patient Population

There are many promising strategies to segment individuals with complex needs. Here is one conceptual framework.

Implementation Tool

January 2016

All Resources

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State

Understanding the Medicare Physician Fee Schedule Billing Codes For: Community Health Integration, Principal Illness Navigation, and Principal Illness Navigation-Peer Support Services

The Return on Investment (ROI) Calculator for Healthcare Partnerships to Address Social Needs

Community Health Worker Model Best Practice Toolkit for Designing, Implementing and Showing Impact

Addressing Social Isolation and Loneliness Among Older Dually Eligible Individuals

Reimbursement Strategies for Employers of Community Health Workers

Guide to Evidence for Health-Related Social Needs Interventions: 2022 Update

Hunger Vital Signs Screening Implementation Guide

Food Bank-Health Care Partnerships

Leveraging Medicaid Accountable Care Organizations to Address Health Equity: Examples from States

Rural Community Paramedicine Toolkit

Food Banks as Partners in Health Promotion: Navigating HIPAA

HOUSED BEDS: A Clinical Tool for Taking a History on an Unsheltered Homeless Patient

A Turning Point in Medicare Policy: Guiding Principles for New Flexibility Under Special Supplemental Benefits for the Chronically Ill

Addressing Health Equity through Health and Housing Partnerships

The ROI Calculator for Partnerships to Address the Social Determinants of Health

Overview of Segmentation of High-Need, High-Cost Patient Population