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What Makes us Different

Solutions, Support, Connections, and Coordination

Centralized Solutions

Through one contract, healthcare organizations receive care coordination services for their members and patients that span multiple risk factors, health and social needs, and geographic regions. We can design a program that is scalable and meets the needs of every healthcare organization.

With Neighborhood Networks, healthcare organizations will:

  • Decrease unnecessary utilization of healthcare services to reduce costs
  • Close care gaps and improve HEDIS scores to improve preventive care
  • Reduce health disparities to advance health equity

Personalized Support

Highly trained Neighborhood Navigators contact community members individually to conduct personalized assessments of health and social needs. Our model includes 21 evidence-based pathways that address the social determinants of health to improve health outcomes. Based on identified needs, Neighborhood Navigators provide education and assistance, connect individuals and families with local resources, and follow up regularly to assure that clients receive the support they need to meet their health goals.


Supportive services provided include:


  • Connect clients with food assistance programs
  • Arrange transportation to medical appointments
  • Provide housing assistance



  • Set and monitor health management goals
  • Coordinate care with primary care providers and across the healthcare system
  • Support adherence to prescribed medications and preventive care


  • Identify diagnosed behavioral health issues
  • Schedule appointments with behavioral health providers
  • Monitor follow-up behavioral health care



  • Assess and address home safety issues:
    • Fall prevention
    • Fire safety
    • Lead exposure
    • Gun safety

Community Connections

Neighborhood Navigators are employed by a network of local community-based organizations that have developed deep, trusting partnerships and understand the local assets and barriers to health in the communities they serve.

Coordinated Management

Neighborhood Networks serves as a “hub” that connects healthcare and community-based organizations. Neighborhood Networks contracts with all partner organizations and provides a variety of management services including specialized training for Neighborhood Navigators, a secure centralized online case management system, quality assurance, and reporting.

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