By Craig Parker, JD, CPA and CEO, Guideway Care

Healthcare experts in Nashville and throughout Tennessee highlight the need for an extended patient support solution for hospitals and provider groups that has the capability to address “pain points” related to patient engagement that leads to clinical, operational and financial challenges. 

As the Centers for Medicare and Medicaid Services (CMS) continues its drive to accelerate the transition away from fee-for-service towards value-based care and increases its emphasis on whole-person health, there is increased focus on health equity and resolution of social determinants of health (SDoH). Hospitals and provider groups are seeking new ways to interact with their patients to find and resolve non-clinical barriers to care while also looking for a competitive edge in the shift to the world of value-based healthcare. Many turn to digital engagement platforms (which are generally not good at solving SDoH problems) or to patient navigation efforts.

The problem is that most traditional patient “navigation programs” lack meaningful patient interaction and prove ineffective. Consider these questions as you evaluate your care coordination efforts:

• Are you seeing significant improvements following post-hospital care transitions with treatment adherence and medication compliance?
• How are your outcomes?
• Have numbers of rehospitalizations and readmissions decreased?
• Have HCAHPS scores and Medicare Star Ratings increased?
• Are they meeting or exceeding your health equity priorities?

If your patient navigation program is not achieving these desired results, it might be time to ask why and consider a deeper, more effective solution that goes beyond mere engagement to interaction with the right patients, about the right things, for the right amount of time.

Tennessee hospitals can follow the lead of health systems nationwide that are finding more value and effectiveness in partnering with a dedicated non-clinical “care guidance” team to extend clinical staff and strengthen patient care management. A structured and scalable care guidance program, one that goes beyond mere patient navigation, can provide a truly effective patient activation and support service that moves the needle in value-based care by reducing readmissions, improving patient satisfaction, increasing wellness visits and site-appropriate care and helping to reduce avoidable acute utilization.

Beyond Mere Patient Navigation

Modern care guidance is an evolution of patient navigation that combines systematized assessments to support disease-specific symptomology with a set of tech-enabled, human-led patient-interaction workflows. The integral role of care guidance serves as a critical extension of a hospital’s clinical team to support a range of goals, including chronic care management, wellness and health equity initiatives, readmission prevention and efforts to improve overall health while reducing costs.

Roots of Modern Care Guidance

This concept of care guidance has its roots in a Medicare-funded effort to study non-clinical patient conversations, with the goal of achieving the “Triple Aim” (better health for populations, better healthcare for patients, reducing healthcare costs). As with many value-based care initiatives, Medicare sought proven approaches to proactively interact with patients to identify, understand and resolve their social determinant-related disparities before the issues became problematic and costly.

In 2012 the University of Alabama at Birmingham (UAB) Health System Cancer Community Network, which included two academic and 10 community cancer centers across Alabama, Georgia, Florida, Mississippi, and Tennessee, was funded by a $15 million grant from CMS. Edward E. Partridge, MD and a team of researchers tested the thesis that a different kind of patient navigation in oncology would be highly effective at addressing patients’ underlying social determinants, which negatively impact their health.

This study was conducted for three years and navigated more than 6,000 patients. The investigators’ analysis, published in JAMA Oncology, reported the program’s significant impact on cost and quality. Savings generated by UAB’s patient navigation program were $19 million per year for a total savings of $57 million. The financial results spoke to the decrease in human suffering though avoidable hospitalizations and ER visits. The study also validated that focusing on SDoH and health equity was the right thing to do. Researchers from CMS and the University of Chicago confirmed the UAB assessment that a different kind of patient interaction and activation was a smart path forward.

Addressing Patient Social Determinants, Resolving Non-Clinical Barriers to Care

Research like the work done at UAB, a renewed national emphasis on health equity and health consequences of the Covid pandemic, have led to greater recognition of the importance of the non-clinical factors that influence a patient’s ability to access, receive and adhere to care. Patients who are at-risk based upon characteristics of SDoH frequently require amplified levels of activation and monitoring that cannot be addressed through patient navigation and within the typical hospital’s resource capacity and clinical scope limitations. When non-clinical factors, which account for 80% of patient issues, are not promptly addressed and effectively resolved, they can lead to health deteriorations, excessive rates of clinical service utilization, extended hospitalizations and readmissions and a higher total cost of care. 

A Patient Activation Solution

Going deeper than mere patient navigation, care guidance provides patients with a higher level of personalized interaction and education to proactively identify barriers that might impact clinical compliance and to find potential indicators of health deterioration earlier. These initiatives serve to enhance the provider’s ability to deliver patient-centered care and generate the best possible health and wellness outcomes with a return to a normal degree of function and quality of life. Hospitals and their clinical staffs receive the extended support they need to advance health equity and deliver care that optimizes patient experience and satisfaction.

The primary objective of many care guidance programs is to promptly identify and resolve a patient’s disparity-driven barriers to accessing, receiving and adhering to care. Innovative health systems are partnering with care guidance services to implement programs focused on prevention and proactive interaction with patients.

How Care Guidance Works

The success of a care guidance program rests on specially selected and tech-enabled “care guides” who work to establish a peer-to-patient connection with patients and their families. This human-led approach builds trust, enhances a patient’s ability to communicate and helps to uncover issues that pose barriers to care. Having worked to uncover barriers and other potential issues, the care guide then works to resolve these issues and assist patients with the overall care journey.

Optimally, care guides are equipped with scalable, technology platforms that provide structured workflows and use evidence-based disease and condition-specific protocols to proactively identify and resolve practical and non-clinical barriers experienced during their care. With this technological support, care guides never have to guess at what their next step should be: they are always on task, finding non-clinical barriers and escalating to the clinical team any information that is potentially clinically relevant.

A Tech-Enabled, Humanized Approach

An effective care guidance platform captures SDoH data analytics and disparity-related barrier resolutions, exceeding the capabilities of typical electronic health record (EHR) systems. A specialized platform facilitates operational improvements by seamlessly exchanging relevant insights for each patient population. By gathering condition- and journey-specific data on thousands of patients, a care guidance platform can take advantage of machine learning to anticipate patient needs based upon condition-specific protocols that enable care guides to deliver an unprecedented level of vital, just-in-time communication. This is different than AI, which is not likely to be successful in facilitating this kind of patient activation unless the AI tool can be trained using the thousands and thousands of journey-specific data points (which don’t actually exist in large EHR systems). Taking advantage of machine learning insights, care guides can better anticipate and communicate the information patients need to better succeed in managing their care journey.

The right mix and integration of human and tech elements support personalized and meaningful peer-to-patient relationships and personalized communication, providing patients and their families with the connected support they need to stay on track and engage in the management of their condition throughout their care continuum.

Conclusion – Value and Benefit of a Care Guidance Partnership

In short, we know the importance of motivated and resourced patients. Unfortunately, most patient navigation programs fail to actually drive patient motivation and clinical compliance in scalable and cost-effective ways. A care guidance program that is scalable and well-designed offers a proven solution to patient engagement that does actually achieve the “Triple Aim”. Care guidance is a cost and time effective connected care solution that allows providers to offload non-clinical work that is “below the top of license” to a dedicated, trained and fully equipped team of care guides. Hospitals can achieve better care and fewer readmissions, while improving their financial and operational performance. And patients are better equipped – and motivated – to manage their healthcare journey.

Craig Parker, JD, CPA, CEO, Guideway Care, has spent most of the last twenty-five years operationalizing solutions that leverage technology and people to improve patient care and outcomes. For more information visit https://guidewaycare.com.