Care Guidance Extends Critical Support of Care Management Priorities | By Tina Graham, Chief Operating Officer of Guideway Care

It has now become clear that hospitals and health systems have entered a new world where persistent staffing shortages increasingly undermine care initiatives, including value-based care needs, and patient expectations. As a result, hospitals are increasingly turning to new solutions that augment their existing capacity — including the innovative service of care guidance programs — to support a range of care management priorities from provider, patient and payer perspectives.

Extending beyond the scope of lay patient navigation, care guidance offers more value and a more effective solution for ensuring care access patient enablement that in turn both advance the goals of health equity. Personalized support from care guides helps patients to resolve non-clinical barriers, thereby removing the burdens on clinical teams who are enabled to focus on their clinical tasks. As a result, hospital administrators have an opportunity to improve operational and financial performance.

Value of Care Guidance

A successful care guidance program delivers a return on investment (ROI) through improved efficiencies, reductions in unnecessary readmissions for which claims are frequently denied and better allocation of the scarce time of clinical care teams. Care guidance delivers high value by supporting the patient journey and helping individuals to not only activate and participate in their healthcare decisions, but to also navigate the complexities of the healthcare system.

For example, nearly everyone agrees that helping patients understanding their discharge instructions, scheduling follow-up appointments, ensuring medication fulfilment and compliance and coordinating transportation can bring benefits, and it’s easy to think of this as the “Transition Care Management” (TCM) solution your hospital has already implemented. But if TCM is working, why do so many hospitals still have excess readmissions, denied readmission claims, and lower than desired HCAHPS scores? The answer almost always lies in three questions: are you talking to the right patients, about the right things, for the right length of time?

With more visibility into how social determinants impact patient outcomes, more providers are wondering how they can improve their performance after an acute episode, while they struggle with staffing and other limitations. Care guidance, which can use highly trained non-clinical personnel to fill in these gaps can be the difference. By streamlining care and connecting all the “moving parts” to care management, patients have a better experience with improved outcomes.

This may also lead to a reduction in avoidable hospital readmissions which disrupt and erode the quality of care delivery and continue to be associated with a significant proportion of healthcare costs. While not all readmissions are avoidable, a portion can be anticipated and prevented pre-and-post-discharge and during their continuation of care. It is especially important for hospitals to prevent unreimbursed readmissions that can cost, on average, upwards of $20,000 per patient.

Finally, care guidance directly impacts clinical staff shortages, particularly nurses who report that a significant amount their workload is burdened by addressing non-clinical patient issues and practical tasks, like scheduling follow-up visits, ensuring transportation and attending to a myriad of practical, non-clinical patient issues. In fact, anywhere from 10-20% of patient issues are recorded as clinical while the other 70-80% are practical and non-clinical in nature. The American Organization for Nursing Leadership’s 2022 Nursing Leadership Workforce Compendium of workplace best practices recommends, among other things, looking for opportunities to offload time-consuming tasks for nurse leaders.

When hospitals offload these non-clinical duties to a care guidance program, they free up resources to provide safe, high-quality patient-centered care with time to handle complex medical cases. This is also proving to increase clinical staff job satisfaction and address clinician burnout, a critical step forward in averting a clinical labor shortage which McKinsey advises is worsening and will contribute to projected increases in healthcare costs over the next five years. 

How Care Guidance Works

The integral role of care guidance, also referred to as “care navigation,” serves as an extension of a hospital’s clinical team to support care management once the patient leaves the hospital setting. These programs focus upon prevention by proactively interacting with patients to understand and resolve their care barriers before issues become problematic and costly. Importantly care guidance programs allow skilled patient advocates to stay engaged with patients long enough to ensure that discharge instructions and other important milestones are actually completed.

The primary goal of care guidance is to ensure that the patient receives the right care at the right time, in the right place and with the right outcome. This is accomplished through 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, lowers a patient’s resistance to sharing information and helps to uncover potential barriers they encounter.

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 non-clinical barriers while also using standard symptom assessments. Through this level of support, care guides ensure that patients are enrolled in the most applicable and supportive programs (such as chronic care management) and can make sure patients are taking advantage of their annual wellness visit benefits. Moreover, when care guides are engaged with patients, clinical issues can be found and immediately escalated to proper clinical care teams.

The human element of care guidance is significant as digital or telephonic engagement simply cannot be a replacement for the human aspect of patient interaction. Certainly, some parts of the overall patient population are satisfied some of the time with purely digital communications. But for the heaviest consumers of high-cost healthcare – Medicare and Medicaid beneficiaries – digital-only solutions frequently don’t really meet the need to understand and activate certain patient population segments. Integrating the “human touch” with technology is most effective identifying and resolving practical and other non clinical barriers to a patient’s continuum of care.

SDoH Insights: Unused Data is Worthless

To identify those most at-risk requires consideration of the full spectrum of a patient’s health, as well as their socioeconomic conditions. Hospitals must recognize the impact non-clinical issues have on patient populations and understand how they underlie health inequities and disparities. For example, social determinants of health (SDoH) can impact a patient’s ability to access, receive and adhere to care. These non-clinical factors include housing, food and nutrition, transportation, social and economic mobility, education and environmental conditions. If SDoH issues and their potential barriers to care are not promptly resolved, they can lead to health deterioration, costly utilization of clinical services and extended hospitalizations.

An effective care guidance program captures SDoH data and disparity-related barrier resolution for operational improvement. This data can supplement the capabilities of electronic medical records (EHR) systems. AI and machine learning can be applied to anticipate patient needs based upon condition-specific protocols that enable care guides to deliver an unprecedented level of vital, just-in-time communication. Led by this intelligence, care guides provide patients with the information they need to engage in the process of their care and empower each patient to receive a better understanding of their treatment plan and compliance options.

Value of Care Guidance

Care guidance is rapidly becoming a “must-have” addition to the service portfolio of health systems, hospitals, and provider organizations. It is at the nexus of new managed care priorities where care guidance represents an innovative approach to advancing heath equity and delivering “high-value, high-quality care.” A highly structured, non-clinical care guidance program serves as an asset for hospitals. Attempting to allocate internal resources to perform the tasks that fall within the scope of care guides could potentially be both inefficient and costly. When an outsourced care guidance program is well designed, implemented and managed, it can provide a significant upside for the hospital, its clinical staff and patients.

Through a care guidance partnership, clinical staffs receive the extended support they need to ensure the delivery of equitable while collaborating with care guides to enhance patient experience, satisfaction with care, resumption of functioning and quality of life. This is where the proposition of a care guidance solution presents the most value for shareholders: a validated approach to equitable and cost-efficient care.

Editor’s Note: Tina Graham, COO, Guideway Care, is an experienced health care executive versed in leading operations teams through the constantly shifting landscape of modern medicine.


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