Coordination and Access
In DevelopmentHelping People Navigate Community Health Resources
Amana Healthcare is developing a care coordination and resource navigation initiative focused on helping individuals and families understand and reach community-based health, food, transportation, and social resources.
The initiative is intended to reduce confusion, close communication gaps between organizations, and make existing community resources easier to use.
- Geographic focus
- Maryland's Eastern Shore and surrounding communities
- Last reviewed
Current Priority
Identifying healthcare, social-service, transportation, housing, food, technology, and funding partners interested in coordinated navigation support.
What This Initiative Is—and Is Not
- This is non-clinical navigation and coordination support only.
- Amana Healthcare does not provide medical case management, clinical care management, or licensed home healthcare services.
- Amana Healthcare does not provide medical advice, diagnosis, treatment, or clinical decision-making.
- Navigation support does not replace care provided or directed by qualified healthcare professionals.
- Any clinical activity would remain the responsibility of appropriately licensed partner organizations.
Initiative Overview
Resources Exist—Reaching Them Is the Hard Part
Many communities already have valuable health, food, transportation, housing, and social resources. People often struggle to find them, understand eligibility, complete applications, or follow up across multiple organizations.
Amana Healthcare's proposed role is to help partners build clear, respectful, non-clinical navigation pathways so people can reach the resources that already exist.
This work focuses on information, connection, communication, and follow-up—not on clinical services.
Resource Clarity
Plain-language information about what exists and who it serves.
Warm Connections
Supported hand-offs instead of a list of phone numbers.
Cross-Organization Communication
Shared, documented pathways between partners.
Follow-Up
Checking whether the connection actually worked.
Resource Domains
Types of Resources Navigation May Cover
Food Resources
Food banks, pantries, produce access, and nutrition programs.
Transportation
Community transit and ride options for appointments and errands.
Community Health Programs
Prevention, screening, and wellness programs run by partners.
Prescription Assistance Information
Information about assistance programs offered by others.
Insurance and Coverage Information
General information and referral to enrollment assistance.
Housing and Utility Support
Local housing, utility, and emergency-assistance organizations.
Social Services
Public and nonprofit benefit and support programs.
Caregiver and Older-Adult Support
Community supports for caregivers and older adults.
Mental Health and Recovery Resources
Information about services delivered by qualified providers.
Community Education
Local classes, workshops, and literacy support.
Amana Healthcare would provide information and connection only. Services themselves are delivered by the partner organizations that own them.
The Community Need
Fragmentation Creates Barriers Even When Resources Exist
People are often referred to a resource with little more than a name or number. Eligibility rules differ, applications are long, offices are far apart, and no one follows up.
Organizations face the same fragmentation: without shared pathways, referrals disappear and duplication is common.
Rural distance on Maryland's Eastern Shore can compound each of these barriers, particularly transportation and limited office hours.
Barriers this initiative may address
Unknown Resources
People do not know what exists in their area.
Confusing Eligibility
Rules differ across programs and are hard to interpret.
Complex Applications
Paperwork and documentation requirements deter people.
Transportation Barriers
Reaching offices and appointments is difficult.
Language Barriers
Information is not always available in preferred languages.
Technology Barriers
Online-only processes exclude some households.
Limited Office Hours
Hours conflict with work and caregiving.
Fragmented Referrals
Referrals are rarely tracked or closed out.
No Follow-Up
No one confirms whether the connection was completed.
Distrust or Past Negative Experience
Prior experiences discourage people from trying again.
This section intentionally avoids prevalence figures and percentages. Statistics will be published only once specific, verified sources have been reviewed and cited.
Potential Participants
Who Navigation Support May Serve
Final eligibility and referral criteria would be agreed with partners, informed by capacity, funding, and privacy requirements.
Geographic focus: Maryland's Eastern Shore and surrounding communities
These are design considerations, not final criteria. No navigation services are currently operating and no referrals are being accepted.
Possible eligibility considerations
- People referred by healthcare or community partners
- Households facing food, transportation, or housing barriers
- Older adults and caregivers
- Participants in other Amana Healthcare initiatives
- People who have had difficulty completing a prior referral
- Residents of the approved service area
Referral considerations
- Referral criteria and consent processes must be defined before any referrals are accepted
- Partners retain responsibility for any clinical follow-up
Proposed Initiative Model
How Navigation Support May Work
This proposed model connects need, inputs, activities, outputs, and intended outcomes. Every element depends on partner agreements, privacy processes, funding, and capacity.
Proposed model, described in sequence: fragmentation, confusing eligibility, incomplete referrals, and limited follow-up create the need. Inputs include healthcare, social-service, transportation, housing, technology, and funding partners plus trained non-clinical staff and a resource directory. Activities include directory development, referral-pathway design, navigation support, application information, warm hand-offs, follow-up, partner communication, and documentation. Outputs include referrals, navigation contacts, resource connections, follow-up contacts, partners engaged, and barriers documented. Intended outcomes include better resource awareness, higher referral completion, reduced burden, stronger inter-organization communication, and better documentation of unmet needs.
Stage 1 of 5
Community Need
- Fragmented resources
- Confusing eligibility
- Incomplete referrals
- Limited follow-up across organizations
Stage 2 of 5
Inputs and Partners
- Healthcare organizations
- Social-service agencies
- Community nonprofits
- Transportation and housing partners
- Technology partners
- Funders
- Trained non-clinical staff
- Resource directory
Stage 3 of 5
Proposed Activities
- Resource-directory development
- Referral-pathway design
- Non-clinical navigation support
- Application assistance information
- Warm hand-offs
- Follow-up contact
- Partner communication
- Documentation
Stage 4 of 5
Proposed Outputs
- Referrals received
- Navigation contacts completed
- Resource connections made
- Follow-up contacts completed
- Partner organizations engaged
- Barriers documented
Stage 5 of 5
Intended Outcomes
- Improved awareness of available resources
- Higher referral completion
- Reduced navigation burden for participants
- Stronger communication between organizations
- Better documentation of unmet community needs
Proposed model, described in sequence: fragmentation, confusing eligibility, incomplete referrals, and limited follow-up create the need. Inputs include healthcare, social-service, transportation, housing, technology, and funding partners plus trained non-clinical staff and a resource directory. Activities include directory development, referral-pathway design, navigation support, application information, warm hand-offs, follow-up, partner communication, and documentation. Outputs include referrals, navigation contacts, resource connections, follow-up contacts, partners engaged, and barriers documented. Intended outcomes include better resource awareness, higher referral completion, reduced burden, stronger inter-organization communication, and better documentation of unmet needs.
Proposed Journey
A Possible Navigation Pathway
Step 1 of 7
Referral or Self-Identification
A partner refers someone, or a person reaches out through an approved channel.
Step 2 of 7
Consent and Explanation
The person learns what navigation includes, what it does not, and how information may be shared.
Step 3 of 7
Needs Conversation
A trained non-clinical navigator listens and identifies practical barriers—no clinical assessment is performed.
Step 4 of 7
Resource Identification
Relevant community resources and eligibility information are identified together.
Step 5 of 7
Warm Connection
The navigator supports contact with the partner organization rather than handing over a list.
Step 6 of 7
Follow-Up
A follow-up contact checks whether the connection was completed and what barriers remain.
Step 7 of 7
Documentation and Feedback
Outputs, barriers, and gaps are documented to improve the pathway.
This pathway is proposed. Actual workflows depend on partner agreements, privacy requirements, staffing, funding, and technology.
Amana Healthcare's Proposed Role
Non-Clinical Coordination and Connection
Amana Healthcare's proposed role is coordination, information, and connection. Amana Healthcare does not perform clinical assessment, case management, or care decisions.
Resource-Directory Development
Building and maintaining an accurate local resource directory with partners.
Referral-Pathway Design
Documenting who may be referred, how, and with what consent.
Non-Clinical Navigation
Practical help understanding options and next steps.
Warm Hand-Offs
Supported connections to partner organizations.
Application Information
Explaining what applications require, without providing legal or medical advice.
Follow-Up Contact
Confirming whether connections were completed.
Partner Communication
Keeping referring and receiving organizations informed within consent limits.
Privacy Process Support
Helping partners define consent, minimum data, and retention practices.
Documentation and Reporting
Documenting activity, barriers, and gaps for partners and funders.
Gap Identification
Surfacing unmet needs where no local resource exists.
Potential Partners
Roles Partner Organizations May Contribute
Healthcare Organizations
Potential contributions
- Hospitals, FQHCs, and community health centers
- Referral criteria and clinical responsibility within their own scope
- Clinical oversight where a need is clinical
- Alignment with community health needs assessments
Social-Service Agencies
Potential contributions
- Eligibility and application expertise
- Benefit program guidance
- Receiving referrals through agreed pathways
- Feedback on referral quality
Community Nonprofits and Faith-Based Organizations
Potential contributions
- Trusted local relationships
- Outreach in preferred languages
- Emergency and short-term assistance
- Community feedback on gaps
Transportation, Housing, and Utility Partners
Potential contributions
- Transit and ride options
- Housing and utility assistance
- Eligibility information for navigation staff
- Coordination on shared participants
Technology Partners
Potential contributions
- Secure referral or directory tools
- Consent and audit capabilities
- Accessible participant communication
- Reporting support
Funders and Evaluation Partners
Potential contributions
- Funding for staffing, technology, and translation
- Measure selection and analysis
- Independent review
- Reporting requirements
Clinical services, medical decisions, and licensed care remain the responsibility of appropriately licensed partner organizations.
Proposed Activities
What Navigation Support May Include
Resource Directory
A maintained, plain-language directory of local resources.
Navigation Conversations
Non-clinical conversations to identify practical barriers.
Eligibility Information
Explaining program requirements in accessible terms.
Application Support Information
Describing documents and steps applications require.
Warm Hand-Offs
Supported introductions to partner organizations.
Follow-Up Contacts
Checking whether the connection was completed.
Partner Coordination Meetings
Regular cross-organization coordination.
Gap Documentation
Recording needs with no available local resource.
Intended Outcomes
What Navigation Would Aim to Achieve
All outcomes are intended. No results have been measured.
Short-term outcomes
- Increased awareness of local resources
- Clearer understanding of eligibility
- More referrals successfully initiated
- Reduced confusion about next steps
Intermediate outcomes
- Higher referral completion rates
- Reduced duplicate outreach across organizations
- Improved partner communication
- Better documentation of unmet needs
Long-term outcomes
- A more connected community resource system
- Reduced navigation burden on households
- Stronger cross-sector coordination infrastructure
- Evidence to inform local resource investment
Navigation support does not by itself produce clinical or health outcomes, and Amana Healthcare will not claim that it does.
Measurement and Evaluation
Measures That May Be Used
Measures would be agreed with partners before implementation, with clear definitions, consent-aware data handling, and documented limitations.
Reach and referrals
- Referrals received
- Navigation contacts
- Participants served
- Referral sources
Connection and completion
- Resource connections made
- Referral completion
- Follow-up completion
- Time to connection
Barriers and experience
- Barriers documented
- Unmet needs identified
- Participant feedback
- Partner feedback
Clinical outcome measures are outside the scope of this initiative and would remain with licensed partners.
Data Responsibility
Privacy and Information Handling
Any navigation initiative would involve sensitive personal information, so privacy requirements must be settled before implementation—not after.
- Collect the minimum information needed to make a connection
- Obtain clear, informed participant consent before sharing information
- Document what is shared, with whom, and for what purpose
- Define partner data responsibilities in written agreements
- Use secure storage and transmission for any participant information
- Restrict access to staff with a defined role
- Define retention and deletion periods
- Explain data practices to participants in plain language
Amana Healthcare does not currently collect, store, or process participant health information. No participant data is collected through this page.
Health Equity and Accessibility
Removing Barriers to Reaching Help
Navigation support only helps if the support itself is reachable. These considerations would shape channels, hours, and communication.
Language Access
Interpretation and translated materials.
Plain Language
Explanations free of program jargon.
Phone and Offline Access
Non-digital channels for households without internet.
Disability Access
Accessible formats, venues, and communication.
Transportation
Options that do not assume a personal vehicle.
Rural Distance
Remote and community-based contact options.
Flexible Hours
Availability outside standard office hours.
Trust and Respect
Non-judgmental support informed by past experiences.
Documentation Barriers
Awareness of documentation people may not have.
Privacy Concerns
Clear consent and control over information sharing.
Development Roadmap
Where the Initiative Stands Today
No navigation services are operating. Phases advance only as partners, privacy processes, and funding are confirmed.
Current phase
Partner and Resource Discovery
- Mapping existing local resources
- Conversations with healthcare and social-service partners
- Identifying referral gaps
Current phase
Pathway and Privacy Design
- Drafting referral pathways
- Outlining consent and minimum-data practices
- Defining non-clinical scope boundaries
Future phase
Agreements and Funding
- Written partner agreements
- Data-sharing terms
- Funding for staffing and technology
Future phase
Technology and Directory Preparation
- Directory build and verification
- Secure referral tooling
- Accessible communication templates
Future phase
Staff Preparation
- Non-clinical navigator training
- Scope and escalation protocols
- Privacy training
Future phase
Pilot Implementation
- Limited pilot with agreed partners
- Documentation of referrals and barriers
- Regular partner review
Future phase
Evaluation and Improvement
- Review of agreed measures
- Participant and partner feedback
- Documented revisions
Questions
Frequently Asked Questions
Connected Work
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Help Make Community Resources Easier to Reach
Amana Healthcare welcomes healthcare organizations, social-service agencies, community nonprofits, technology partners, and funders interested in building practical, non-clinical navigation pathways.
Conversations are exploratory. No services, referrals, or funding commitments are implied.