Patient navigation works. Running it at scale is the hard part.

Patient navigation is one of the better-supported interventions in healthcare operations. Randomized trials show that navigators help more patients complete screenings and follow-up procedures, and Medicare has paid for some navigation since January 2024. Yet early claims data show very little use of the Medicare navigation codes. For health-system leaders, the evidence question is largely settled. The open question is operational: how to run navigation as dependable capacity rather than a handful of dedicated roles.

What is patient navigation?

Patient navigation helps patients overcome the specific barriers between them and a recommended step in their care. The Community Preventive Services Task Force describes navigation services as doing one or more of three things: reminding patients, reducing structural barriers such as scheduling, transportation, translation, or childcare, and reducing out-of-pocket costs. A patient navigator may be a community health worker, nurse, social worker, dedicated navigator, or other trained staff member.

Care navigation is often used more broadly, for help finding the right service or site of care. The distinction matters for planning. The strongest evidence is for navigation tied to a defined next step.

What the evidence shows

The Task Force reviewed 34 studies and in 2022 recommended patient navigation to increase breast, cervical, and colorectal cancer screening among historically disadvantaged racial and ethnic populations and people with lower incomes. In its meta-analyses, navigation was associated with higher colorectal cancer screening (risk ratio 1.82 across 26 studies) and breast cancer screening (risk ratio 1.32 across 10 studies). The Task Force found navigation for breast and colorectal screening cost-effective and judged the return on investment favorable for navigation to colonoscopy. Nearly half of the studies delivered navigation entirely by phone or other remote contact.

Recent trials point the same way:

• A 2025 randomized trial in Annals of Internal Medicine enrolled patients with an abnormal stool test across 32 clinics of a Washington federally qualified health center. A six-topic telephone program delivered by bilingual clinical staff raised one-year follow-up colonoscopy completion to 55.1%, compared with 42.1% under usual care. The trial ran largely during the COVID-19 pandemic.
• A 2024 randomized trial in JAMA Internal Medicine at Boston Health Care for the Homeless Program enrolled 260 patients. Lung cancer screening completion at six months was 43.4% with navigation, compared with 9.2% with usual care alone.

The second trial also shows what navigation work looks like. Navigators averaged 9.6 contacts per patient, almost all by phone. Patients who completed screening averaged 12.8 contacts, compared with 7.2 for those who did not. In practice, navigation is a sustained series of conversations.

Where the evidence stops

Navigation is not a general fix for high-cost patients. In the Health Care Hotspotting trial published in NEJM, 800 hospitalized patients with complex medical and social needs were randomized to an intensive care-transition program or usual care. The 180-day readmission rate was 62.3% in the program group and 61.7% in the control group, a difference that was not statistically significant.

The trial carries a second lesson. A simple before-and-after look at the program group would have suggested a 38-percentage-point drop in admissions. The control group declined by a similar amount. Without a comparison group, the program would have looked highly effective.

The takeaway is not that navigation fails. Navigation produces its clearest results when it is aimed at a specific, measurable step and evaluated against a credible comparison.

Medicare pays for navigation. Few practices bill it.

Since January 1, 2024, Medicare has paid for Principal Illness Navigation (PIN) under the Physician Fee Schedule. According to CMS guidance, PIN applies to patients with one serious, high-risk condition expected to last at least three months that places them at significant risk of hospitalization, nursing home placement, acute exacerbation, functional decline, or death. CMS lists cancer, COPD, heart failure, dementia, HIV/AIDS, severe mental illness, and substance use disorder as examples.

The requirements are operational. PIN must follow an initiating visit with the practitioner who will bill for it. Consent must be obtained before or when services begin and renewed annually. Trained auxiliary personnel can deliver the service under general supervision, including by phone or other telecommunications, and their time and activities must be documented.

Uptake has been minimal. A January 2026 study in JAMA Health Forum analyzed all 2024 professional claims in traditional Medicare. It found 7,934 PIN services submitted nationwide, 2.8% of the 285,270 services billed for health-related social needs. Medicare reimbursed 85.4% of submitted PIN services, a total of $440,168. For these services overall, the authors point to misaligned infrastructure, staffing, and workflows, and suggest documentation requirements may impede adoption.

The study has limits. It covers only the first year and only traditional Medicare, and it cannot explain why individual practices did or did not bill. It says nothing about 2025 or 2026. Still, the gap between strong evidence and low early use looks more like an operations problem than an evidence problem.

How to run patient navigation as operating capacity

A patient navigation program scales when it is managed as a workflow. Five design decisions matter most.

1. Choose the next step, not just the population. Define the outcome navigators own, such as a follow-up colonoscopy after an abnormal stool test or a first treatment appointment after a diagnosis.
2. Build the work queue from data. Abnormal results, unscheduled referrals, and missed procedures should create navigation tasks automatically, instead of relying on clinician memory. The Task Force notes that programs should check for electronic health record tools that identify patients who would benefit.
3. Staff for conversation volume. If patients who complete a step need a dozen contacts, capacity plans should count contacts, attempts, and language needs, not only enrolled patients.
4. Design billing requirements into the workflow. For organizations pursuing PIN, the initiating visit, consent, supervision, and time documentation should be captured where the work happens.
5. Measure completion against a comparison. Track completion rates and time to completion for navigated and non-navigated patients, so results reflect the program rather than regression to the mean.

PEC360's perspective: navigation is a coordinated conversation

PEC360 treats patient experience as an operations problem, and patient navigation is a clear example. The trials above succeeded through repeated, well-timed conversations that moved patients toward one completed step. The barriers the Medicare study describes, staffing, workflow, and documentation, are the same barriers that limit most outreach programs.

PEC360's platform is built around that problem. Connect360 prioritizes patients who are overdue for recommended visits, screenings, procedures, and follow-up care. It coordinates live-agent, AI voice, and text outreach around the same patient need and keeps outcomes visible. PEC Central gives agents real-time knowledge and workflow guidance during those conversations, and Insights measures care-gap closure performance and interaction quality. Sherlock EKOL can organize the care-gap knowledge those workflows rely on. For organizations short on staff, PEC360 also provides outsourced Care Advocates.

In PEC360's view, the five decisions above form one operating loop. Data identifies the patient and the step. Prioritization decides who is contacted first. The right channel, whether automated voice, text, or a live agent, makes the contact. Agents work from current knowledge and approved workflows. The outcome is recorded, so leaders can see completed steps rather than only call activity. The same loop applies whether the step is a screening, a referral, or a follow-up visit.

Automation suits reminders, routine contact, and keeping the queue current. Solving barriers, building trust, and making clinical judgments still belong with trained people. PEC360 does not determine PIN eligibility or billing compliance. Those decisions remain with the billing practitioner and the organization's compliance team.

The takeaway

The case for patient navigation no longer rests on promise. The evidence supports it for specific steps, and Medicare now pays for some of it. What separates a pilot from a durable program is operating discipline: a defined next step, a data-driven queue, enough conversation capacity, documentation built into the work, and honest measurement.

Authoritative sources

1. Community Preventive Services Task Force. Cancer Screening: Patient Navigation Services to Increase Breast, Cervical, and Colorectal Cancer Screenings and Advance Health Equity. Finding and rationale statement, ratified July 2022. DOI 10.15620/cdc/164181. https://stacks.cdc.gov/view/cdc/164181/cdc_164181_DS1.pdf
2. Coronado GD, et al. Patient Navigation to Improve Colonoscopy Completion After an Abnormal Stool Test Result. Annals of Internal Medicine. 2025;178(5):645-654. DOI 10.7326/ANNALS-24-01885. https://www.acpjournals.org/doi/10.7326/ANNALS-24-01885
3. Baggett TP, et al. Patient Navigation for Lung Cancer Screening at a Health Care for the Homeless Program: A Randomized Clinical Trial. JAMA Internal Medicine. Published June 10, 2024. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2819819
4. Finkelstein A, Zhou A, Taubman S, Doyle J. Health Care Hotspotting: A Randomized, Controlled Trial. New England Journal of Medicine. 2020;382:152-162. DOI 10.1056/NEJMsa1906848. https://www.nejm.org/doi/full/10.1056/NEJMsa1906848
5. Centers for Medicare & Medicaid Services. Community Health Integration, Principal Illness Navigation, and related services frequently asked questions. https://www.cms.gov/files/document/health-related-social-needs-faq.pdf
6. Billig JI, et al. Early adoption of services for health-related social needs in traditional Medicare, 2024. JAMA Health Forum. Published January 23, 2026. DOI 10.1001/jamahealthforum.2025.6261. https://jamanetwork.com/journals/jama-health-forum/fullarticle/10.1001/jamahealthforum.2025.6261