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Social Care Services Evidence Summary: Navigation Access Functions

This evidence summary includes a broad range of research/resources on navigation access functions and is primarily focused on health care 

impact. It is not intended to be an exhaustive compilation of research/resources on this topic. The information presented in this summary can 

inform the value proposition of partnering with a community-based organization (CBO) or a network of CBOs to offer these services and 

supports as part of a strategy to address social determinants of health (SDOH).

Aging and disability networks are well equipped to support individuals and families in navigating long term services and supports (LTSS) and,

increasingly, social care services that address SDOH such as housing, transportation, and food insecurity. As community-based providers, aging 

and disability networks are trusted experts on the resources within their respective communities. A key way in which aging and disability 

networks support individuals, families, and caregivers is by assisting with the navigation of social services, eligibility, and resources in order to 

provide community members with the information they need to make informed decisions. This navigation support can take several forms,

including:

• Information and Referral (I&R): The art, science, and practice of bringing people and services together. As part of a No Wrong Door

system, aging and disability providers follow policies and procedures for the delivery of I&R services using person-centered practices 

that promote informed decision-making about the services and supports available to them1. 

• Options Counseling: The assistance in identifying goals and needs through person-centered counseling and coordinating access to 

publicly and privately-funded long-term services and supports in the community2. 

• Benefits Access: The identification of public and private benefit programs for which older adults and individuals with disabilities may 

qualify so that they can remain healthy, secure, and live independently within their communities.

While aging and disability providers may use different terms to describe these functions, the core values around navigation support remain the 

same. Navigation functions connect community members with a range of services that help them to independently live safely in their 

communities. This range of services that the aging and disability network supports navigation to, such as housing, transportation and meal 

services, as demonstrated in other social care services evidence tables, have the potential to reduce hospitalizations, emergency department 

visits, and other high-cost services, as well as caregiver burnout and stress. In turn, navigation services have the potential to support cost saving 

efforts of health plans and health systems. The aging and disability network is well primed for partnership with health plans and systems 

interested in supporting their members with greater access to community resources and social care services through person-centered navigation 

access functions. 

1 https://www.airs.org/i4a/pages/index.cfm?pageid=3500

2 https://www.aging.ca.gov/Programs_and_Services/Aging_and_Disability_Resource_Connection/
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Research and resources related to navigation functions provided by aging and disability networks are included below. Exploration of the impacts 

and outcomes associated with navigation access supports provides an area of opportunity for future research and investigation.

Navigation Functions Research

Study Population Studied Objective of Study Type of Analysis Findings / Results

Oregon Department of 

Human Services (2018)

Oregon Aging and 

Disability Resource 

Centers (ADRCs)

To make the 

business case that 

the benefits of ADRC 

services, including 

options 

counseling/personcentered counseling,

exceed the cost to 

run ADRC programs.

Social return on 

investment

The analysis concluded that there is 

a strong business case for Oregon’s 

ADRCs. The estimated social return 

on investment of the ADRCs in 

Oregon is 11.1 to 1. The benefits in 

Oregon totaled $39.8 million at a 

cost of $3.6 million in 2016-2017.

Navigation Functions Resources

Resource Author Description of Content Target Audience

Kaiser Permanente Community Health

(2018)

This article provides a detailed overview 

of San Diego’s 2-1-1 program and a 

description of their Community 

Information Exchange (CIE) tool and its 

demonstrated success, along with lessons 

learned. 

Health systems and organizations interested in 

learning more about CIE tool and its demonstrated 

success across different hospitals.

National Council on Aging (NCOA) This webpage provides an overview of 

the number of benefits available to 

Americans aged 65+, details the value of 

these benefits, and highlights NCOA’s 

Center for Benefits Access and their 

Benefits CheckUp tool. 

Older adults and family members unsure of the 

benefits available to them or in need of assistance 

connecting to a range of services. 

NCCARE360 This website provides information on 

North Carolina’s 2-1-1 network and how 

many counties, organizations, and users 

Individuals and organizations in North Carolina 

interested in being connected with services within 

the state or becoming a part of the network.
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Resource Author Description of Content Target Audience

they have reached through this effort and 

hosts a 2-1-1 tool to find resources in the 

state.

Topi & Auger (2018) This slide deck presents an overview of 

the MassOptions tool and details the 

technology platform, features and 

benefits, social media strategy, reporting 

and analytics, the referral exchange 

portal, and more.

Those interested in a comprehensive overview of

the MassOptions tool or are interested in 

designing their own platform.