How care guidance support works

The transition from the traditional fee-for-service health care model to value-based care (VBC) is accelerating, with CMS and numerous commercial payers adopting Alternative Payment Models (APMs) that tie economic incentives to meeting health equity and quality of care objectives. For physician practices, ACOs and IDNs, this signals a significant change in reimbursement that will challenge many organizations’ capabilities for finding and resolving challenges of at-risk patient populations who experience health inequities attributed to social determinants of health (SDoH) and other disparities.

This fundamental change in reimbursement/payment further aligns with recommendations from The American Medical Association (AMA) that encourage physicians to examine their own practices to ensure equality in medical care. With increased awareness of the impact of social determinants and health equity factors, physician practices are now putting more focus and priority on health equity to meet the socioeconomic needs of their patients. Payment incentives clearly represent the next step toward ensuring that organizations heed these directives.

As an extension of a physician’s clinical care team, the implementation of care guidance programs can help medical practices to effectively address the issues surrounding health equity, provide a more uniform care experience that optimizes patient engagement and satisfaction and avoid unnecessary acute care (emergency room visits and hospitalizations/readmissions). Non-clinical care guidance has been proven to lower the total cost of care in value-based arrangements and has a beneficial impact on both patient experience and provider financial performance.

How Care Guidance Works

Care guidance programs consist of several components, including specially selected and trained non-clinical care guides who are equipped with scalable, technology-enabled platforms that provide structured workflows and who use evidence-based disease and condition-specific protocols to gain valuable insights into each patient.

Care guides establish a deep and ongoing relationship with patients and their families. Serving as the main patient point of contact, this peer-to-patient connection can lower resistance to sharing personal information and provide individuals with the information, motivation and access they need to act and engage in the process of their care.

Optimally, care guides are empowered to proactively identify and resolve practical, non-clinical issues and barriers to care that are experienced during the patient care journey. By following structured, AI-assisted workflow protocols, care guides ensure that clinical issues are immediately escalated to proper clinical care teams and that no non-clinical or social issues fall between the cracks.

Tech Enabled Care Guidance with a Human Touch

Although technology platforms have played a role in increasing patient engagement, they frequently fall short of driving true patient activation. Persistent and consistent communication with a person viewed as a peer (the care guide) is key to finding and resolving non-clinical obstacles (such as practical barriers, low motivation, lack of sufficient information or resources). Led by the intelligence and insights of technology resources, care guides provide patients with the information, motivation and resources they need to resolve barriers so they will engage in the process of their care and receive a better understanding of their treatment plan and options.

While high-tech capabilities such as AI, machine learning and data analytics are critical for anticipating patient needs and identifying probable SDoH risks, it is the human touch of care guides that the makes the difference in providing an unprecedented level of vital, just-in-time human communications with patients. This is critical because as reported in a recent CX Trends & Insights report by Execs In The Know, most patients prefer human interaction over other technology engagements or forms of self-help.

As these recent reports demonstrate, digital engagement simply cannot be a replacement for the human aspect of patient interaction. To be certain, chatbots and other technologies continue to get better at identifying causes of frustration, confusion or anxiety, but they struggle to provide real-time problem solving when the underlying root cause has multiple factors (think financial difficulty, transportation issues, confusion over which medicine to take, and which provider appointment should be prioritized).Over time, the peer-to-patient relationships create trust as decompressing conversations with the patient, or their loved ones, opens the opportunity to find more of the non-clinical issues that are confronting both patients and caregivers. This includes identifying personal preferences that enhance a patient’s consumer experience (CX) and advance provider and payer aspirations to deliver patient-centric care.

Care Guidance Supports National Organizations Aimed at Equitable Care

Policymakers, regulators and payers play a critical role in setting standards for measuring the efficacy of health equity initiatives and introducing reimbursement strategies that incentivize equitable care. The newly formed National Alliance to Impact the Social Determinants of Health (NASDOH), a national advocacy organization of healthcare industry stakeholders, aims to focus national attention on SDoH to improve health and well-being while reducing long term spending.

The increasing focus on health equity, social determinants and health related social needs is also demonstrated by the addition of the Social Need Screening and Intervention (SNS-E) HEDIS metrics requirements published by the National Committee for Quality Assurance (NCQA).According to NCQA leaders, these new measures are part of an organization-wide effort to advance health equity and encourage providers and health plans to assess and address the food, housing and transportation needs of populations.

While the focus on health equity is a huge step in the right direction, unfortunately, many providers are already experiencing staffing challenges. Adding a commitment to find and address non-clinical barriers is hard for teams that are used to spending their time in the clinical world. Fortunately, non-clinical care guidance can solve this staffing shortage in a highly efficient way. And the good news is that while doing good for patients, care guidance also helps improves a variety of satisfaction-related scores such as CAHPS and Medicare Stars Ratings through persistent and consistent patient interactions and the active identification and resolution of health care barriers related to SDoH.

Care Guidance Aligns with Quality Payment Programs and Alternative Payment Models

In addition to creating incentives to highlight the importance of increasing health equity, payers like CMS have also introduced an array of programs that emphasize value and quality as key components of the healthcare funding ecosystem. For instance, CMS’ Quality Payment Programs (QPP) act as the value component for the Accountable Care Organization (ACO) model for coordinated high-quality care to Medicare patients. State Medicaid funds are adding similar incentives, such as Maryland’s program to reward hospitals for ensuring patients have a prompt follow-up appointment after an emergency room visit. As the focus on value (and quality) accelerates, finding and resolving SDoH will grow in importance to qualifying for many of these value incentives, including the Merit-Based Incentive Payment System (MIPS), which adds incentive payments to providers for their patient scores, rewarding or in some cases penalizing them for their scores related to high-quality and cost-efficient care.

Care guidance is a perfect extension of QPP models. The key to unlocking these value-based incentives is to find better ways to interact with patients – especially outside the clinic walls and in areas of critical need, such as SDoH.

Validating Care Guidance

Care guidance has been validated by CMS to reduce hospital utilization, including unnecessary emergency room visits and in-patient admissions and it is becoming an essential tool to address the total cost of care as well as influencing significant improvements in patient appointment attendance, health outcomes, CX and reported satisfaction and quality metrics in VBC.

We know that many organizations have struggled to measure the impact that their investments in health equity and social determinants are making. Care guidance finally solves that problem by showing positive returns on investment in the form of better access, reductions in unnecessary utilization, better financial performance and increased patient satisfaction. The addition of a care guidance program beyond legacy navigation efforts provides organizations with truly effective support services, functioning as a lower cost extension of their clinical teams and freeing up labor, time and resources so that clinicians can focus on high-value clinical tasks.

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.

Edward Partridge, MD, Chief Medical Officer of Guideway Care, is Director Emeritus and Professor Emeritus of the UAB Comprehensive Cancer Center and Medical Director, UABHS Cancer Community Network. Dr. Partridge served as President of the National Board of the American Cancer Society, Chairman of the Commission on Cancer for the American College of Surgeons and sits on the Board of Directors of the Mid-South Division of the American Cancer Society.