Problem being addressed In a medically under-served rural Canadian community where overburdened family physicians provide most of the cae for patients with mental illness and substance use problems, providing access to timely and effective help for all citizens is a challenge. The care burden of unmet mental health needs is experienced throughout the larger community by diverse community service providers.Supporting a shared understanding of the needs and challenges, and ensuring effective connection and clear communication between diverse disciplines in primary care, community services and the formal mental health system requires models of service organisation and delivery that go beyond traditional clinical roles.In cancer care a navigator model has previously been used to address information and service gaps and improve patient experience. We wished to evaluate whether a community-supported navigator model could help solve some of the challenges for clients and service providers in our community, while at the same time allowing data collection that offers a clearer understanding of actual service needs.Pre-programme activities Community members formed an interdisciplinary community steering committee which met monthly for two years to develop and adapt a service and collaborative research model, generate support, secure ethical approval and raise funds.Programme description The navigator service was embedded in a local family service organisation, the steering committee met monthly, and along with the researchers met regularly with programme staff and provided support, oversight and development of ethical data collection.Navigators provided low barrier access, comprehensive assessment, collaborative service planning, and linkage and referral facilitation for any individual or family who requested assistance with a mental health or substance use concern. Navigators also serve as an information resource for any community service provider or family physician needing to assist a client, and collected data on local service needs.Conclusions Analysis of quantitative administrative data, consented research data, and qualitative interview and survey data demonstrated that this community supported navigator service model was effective in improving service access, assessment and linkage for citizens with mental health and addictions concerns, and connecting a range of community services into a more effective network of care. Connecting unattached clients with a primary care provider and supporting needs assessment and service planning for patients of local family physicians were key navigator functions.