Ben Albert

Care navigation can enhance a patient's care journey, but hospitals often face obstacles in mapping out such an initiative.

At a Glance

Developing a care navigation model involves a five-step process:

  • Determine areas of risk, such as high readmission rates and patient populations that pose a financial challenge for the organization (e.g., patients with congestive heart failure).
  • Decide which patient populations will serve as the target populations.
  • Find the right staff to support the model.
  • Outline protocols and best practices.
  • Expand the scale of the program.

When was the last time you read a map? Today, we can access technologies such as global positioning systems that are designed to guide us where we need to go. In health care, however, patients traditionally have not had even a paper "map" to consult to guide them through care processes, delivery systems, and treatment, let alone step-by-step navigation for their care.

Care navigation is gaining traction in health systems, community-based health initiatives, and primary care practices. Clinically skilled care navigators spend time with patients on behalf of physicians and hospitals, reviewing critical details such as medication schedules and symptom management with patients and their families. They engage additional resources for patients, such as community pharmacist assistance and administrative support, where necessary.

Care navigators also provide a bridge between appointments with physicians. They tend to patients' needs and help keep patients on track with care plans while eliminating unnecessary resource consumption, such as trips to the emergency department for care that could be provided in an office setting.

The use of care navigators has been proven to enhance patient satisfaction. At Cleveland Clinic, patient service navigators provide personalized guidance and support to patients and their families each day, collaborate with nurses in resolving patient concerns, and empower patients to take an active role in their care. Their efforts have led to improvements in HCAHPS scores in a variety of areas, such as staff responsiveness and pain control (Focus on the Patient Experience, Cleveland Clinic, Spring 2010). In northeast Ohio, use of care navigators has resulted not only in higher HCAHPS scores, but also in reduced costs related to canceled appointments and no-shows; the cost savings in the first few months of the initiative covered the salary of the care navigator ("Panel Event Examines Growing Role of Patient Navigators in Northeast Ohio," Center for Health Affairs, Oct. 31, 2012).

Despite the apparent benefits of care navigation, however, the effort to change fundamental care delivery processes to support the role of a care navigator (sometimes referred to as a "care manager" or "care coordinator") is not without obstacles.

Most physician offices and health systems have spent years perfecting their processes around a fee-for-service payment model. Many providers believe that hiring care navigators adds to a hospital's or physician practice's overall costs while discouraging revenue-generating patient visits. This can be true-if care navigation is not supported with data analysis and the right model for care management.

But the benefits of care navigation will soon become evident in an environment of healthcare reform and shared-risk agreements. Care navigation models can be applied across multiple patient populations. The use of care navigators will soon become a core competency in the provider setting: Care navigation models form the basis for tackling some of health care's most deeply rooted problems, such as preventable readmissions, system leakage (referrals and admissions outside of a hospital's or health system's partner networks), and redundant and expensive tests.

Before care navigation can truly take root, several challenges must be managed into opportunities. Following are five steps for developing a care navigation model that hospitals, health systems, and physician practices should consider.

Determine Areas of Risk

A care navigation model that can mitigate an organization's level of risk and exposure takes time to pull together. It is important to first identify where your organization's exposure to risk exists.

For example, are there specific patient populations, such as Medicaid self-pay patients, for whom care navigation could improve quality of care and significantly reduce costs? Does your rate of readmissions put your organization at risk for financial penalties from the Center for Medicare & Medicaid Services (CMS)? Are there opportunities to enhance revenue by providing care navigators for specific patient populations? Some payers, including CMS, are paying as much as $20 per attributed patient per month to providers to manage care.

Hospitals, health systems, and physician practices are most likely losing money on at least one patient population-often patients with congestive heart failure (CHF). The average cost to care for some CHF admissions can exceed payment-even before readmissions penalties are considered. By understanding your organization's current losses as well as potential losses, you can best assess what type of investment you can afford to make to help address weaknesses.

Identify a Target Population

This past October, CMS's readmissions reduction program went into effect, with hospitals facing monetary penalties for excess readmission rates for heart attack, heart failure, and pneumonia. According to a Kaiser Health News analysis, 1,422 hospitals will lose slightly more money than expected under the program's revised rules for excess readmissions, while only 55 hospitals will lose less money than anticipated (Rau, J., "Medicare Revises Hospitals' Readmission Penalties,", Oct. 2, 2012).

Many organizations have already begun to examine their financial risk related to these conditions. Dig deeper: Conduct a thorough review of your patient load by risk, payer, diagnosis, and care setting. You might be surprised to discover a few new holes in your organization's bucket. Examine your referral partners: Are patients consistently being readmitted from the same skilled nursing facility? Are your partners referring patients to facilities outside your organization? What is your true cost of care for a chronically ill patient? Does it exceed the resulting payment? Is your health plan self-funded?

Answers to questions such as these can help you identify the populations for which care navigation can produce a clinical or financial ROI. The successful launch of a care navigation initiative-even on a smaller scale-establishes the groundwork for the future of accountable care while improving clinical outcomes and generating positive financial results.

MissionPoint Health Partners, part of Saint Thomas Health in Nashville, and Detroit Medical Center's Michigan Pioneer Accountable Care Organization (ACO) Model are both excellent examples of this approach. MissionPoint began its ACO to navigate care for its self-funded health plan population. Since then, it has expanded the program-by implementing a Medicare Shared Savings Program, for example-to support additional populations. The Michigan Pioneer ACO, one of 32 Pioneer ACOs, began by managing Medicare patients; it will soon expand to manage care for the state health plan population.

CMS and a collection of commercial payers in Michigan designed the Michigan Primary Care Transformation Project (MiPCT) in 2011 to sustainably improve overall population health. Initiatives included efforts to reduce health risks for healthy individuals, provide self-management support for patients with moderate chronic disease as well as care coordination and support for patients with severe chronic disease, and ensure access to appropriate, coordinated end-of-life care. The program requires participants to maintain a specific patient-to-care manager/navigator ratio and pays participants a monthly fee per patient. MiPCT supports more than 1.1 million patients across Michigan.

Find the Right Staff to Support the Model

The most important step in developing a care navigation model is to identify the people who will help manage a patient's care journey as well as the model itself.

As with any operation, the attributes of staff can mean the difference between success and failure. Remember, the goal of care navigation is not to medically manage all patients; rather, the goal is to help most patients navigate the system themselves, while medically managing patients who truly need a higher level of support. This is a critical distinction. Nurses are trained to insist upon managing every detail of a patient's care. Care navigation requires a different mindset, one that balances clinical aspects of patient care with business sense to determine the amount of time that should be invested in managing each patient's care.

The most successful teams are often led by or include an individual who understands the care navigation and care management process from a nurse's point of view and who has demonstrated the ability to move into a business administration role. Hiring a leader who can be both player and coach is essential. The care navigator should have excellent communication skills, not just to foster patient and family engagement, but also to promote the mission of care navigation to partners in finance, IT, compliance, the medical staff, and clinical care. Experience in multiple care settings is a positive, because one requirement of the job is to build strong working relationships with care partners across the continuum. Without a nursing perspective at the table, dissension will erupt among those providing the care and those making the decisions, resulting in a cracked foundation from the start.

This leader should assemble or be surrounded by a team of care navigators, care managers, and administrative personnel to support the patient population. Care navigators should have incentives to maintain objectivity, walking a fine line between managing a patient's care and helping the patient navigate care. Care navigators have a big job: They are responsible for patients, but they also are responsible for documenting interactions, coordinating community resources, managing internal politics, and supporting the organization's reporting needs. This is a lot to ask of any role.

Sometimes the team's structure, decision- making process, and responsibilities can be the primary challenge for care navigators. A care navigator's skills should align with the patient population being supported and the design of the program. For example, if the program is underpinned by technology, care navigators should be comfortable working with computer software that supports the program's long-term success.

Integrated Health Partners (IHP) of Battle Creek, Mich., has leveraged a patient-focused care navigation model since 2009. IHP uses process mapping to identify barriers to enhancing the efficiency and quality of care, provides automated reminders to care navigators and physicians related to patient health screenings and disease management, and collaborates with community agencies to ensure patients receive the support they need. IHP's executive director is a nurse whose intimate understanding of the care navigation process and the financial needs of her physician organization have been instrumental in ensuring its successful participation in shared-risk programs, including the multipayer MIPCT, the largest patient-centered medical home project in the nation.

Outline Protocols and Best Practices

Before engaging with patients, it is crucial that time be spent developing and documenting a strategy for engaging the entire continuum of care through care navigation. Tried-and-true clinical judgment should be the basis for the model's protocols, but clinicians are not needed to support the fulfillment of every activity.

Leverage administrative resources to support nonclinical tasks, such as appointment setting, to ensure timely follow-up and prevent system leakage. Align both existing partnerships and new relationships alike with the goals, objectives, and processes of the care navigation initiative so that everyone will be on the same page. A care coordination platform to support providers' work documentation requirements, identify the patients who need support, and enable scalable and patient-specific cross-continuum communication should be implemented to avoid redundancies and accurately measure performance. This approach will reduce the time spent caring for each patient while improving both clinical and financial outcomes.

Stratifying patients by risk of readmission and/or ability to self-manage care is an effective way to ensure the care navigation model will serve more patients with fewer FTEs. Planning for patients by risk as opposed to DRG can allow you to mitigate your organization's financial exposure more effectively. This approach requires more documentation related to best practices and protocols, however. Such documentation helps take the guesswork out of processes and protocols for care navigators and provider partners while giving family caregivers an opportunity to participate in their loved ones' care with confidence. Having the right protocols in place ensures that patients receive the right treatment in the proper care setting.

Finally, define the method that will be used to measure performance, and leave room for adjustments in your program design. Reporting helps identify gaps in care, and based on your data, you may find it necessary to weed out referral partners that are not supporting the organization as expected.

Remember, too, that there is no "one-size-fits-all" design. Localize the program to the patient population and community it supports. These action steps have been successfully used by organizations that previously found the implementation and scaling of care navigation protocols difficult to enact on a broad basis.

Expand the Scale of the Program

Once you have experienced success with care navigation for a targeted patient population, design ways to extend the reach of the program to other populations. By starting small, you can perfect processes and give care navigators increased confidence in their ability to make a difference for patients. Investment in care navigation will pay great dividends when the initiative is extended to other loss-leading patient populations.

Be sure also to document successes. Build a creative, subtle marketing campaign centered on positive outcomes and patient satisfaction so that care navigation becomes a differentiator for the organization. Such marketing also will help with physician recruitment efforts, as physicians naturally desire to be on a winning team.

A Road Map for Success

Proper planning and prudent financial investment in establishing a top-flight care navigation program will serve as your organization's road map to success under value-based business models of care.

CFOs and other leaders tasked with keeping an eye on the bottom line should take the long view when examining the viability of care navigation. Visionary leaders always think two steps ahead. Deploying a well-planned care navigation program can generate tremendous returns for patients as well as for a healthcare provider's business in the short and long term.

Ben Albert is founder and CEO, Care Team Connect, Evanston, Ill. (


Publication Date: Monday, December 03, 2012

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