Studies show that persons with lower economic and social status tend to experience a lower quality of healthcare.a Although U.S. health systems are increasingly using artificial intelligence (AI) and data technology to identify these populations and the obstacles they face related to social determinants of health (SDoH), results have tended to fall short of effective action.
Care guidance offers health systems a more direct way to serve patients on the margins of our healthcare system. It adds a tech-enabled, human touch approach for reaching at-risk patients to uncover and resolve nonclinical issues that are impeding their ability to access and receive care. In fact, clinical care is estimated to account for only 10% to 20% of the modifiable contributors to a patient’s well-being and healthy outcomes for a population. The other 80% to 90% are considered nonclinical issues tied to SDoH factors unrelated to clinical care.b
How care guidance works
In a care guidance program, specially trained and managed nonclinical care guides — also called care navigators — establish connected relationships with patients and their families. By serving as a patient’s main point of contact with a health system, a care guide offers patients guidance on how to engage in their care processes and, as a result, helps lower patients’ resistance to sharing personal information. Care guides function as an extension of a health system’s clinical care team, reaching patients beyond facility walls to improve their treatment adherence, care experience and health outcome.
After connecting with such patients, care guides follow condition-specific protocols, assisted by AI and machine learning, to proactively identify and resolve nonclinical issues and barriers that are impeding access and delivery of care. Technology tracks all patient and caregiver interactions, including phone calls, digital messaging, steps to identify issues and resolve barriers, and resource utilization and clinical escalation points in a single platform. Capturing clinical work allows for tracking productivity, ensures no issues are left unresolved and automatically provides direction for next steps.
Value comes from the human touch
Technology is intended only to support care guides. A care guide’s most essential quality is their abiltiy to show humanity in building relationships of trust with patients over time. Only by showing compassion can a care guide gain a patient’s confidence to discuss the challenges the patient is facing.
For example, if a diabetic patient could not afford the copay for their insulin and had almost finished their current prescription, the patient could inform the care guide, who could reach out to the manufacturer and secure a one month’s supply for free, providing the patient’s pharmacy with the information required to fill the prescription.
The value of care guidance is in humanely helping patients meet unaddressed needs that otherwise might go unrecognized and unresolved. Benefits include:
- Resolving practical issues and nonclinical barriers to care that improve patient treatment adherence, care experience and health outcomes
- Ensuring that clinical issues are immediately escalated to proper clinical care teams
- Supporting, by extension, clinical and nursing teams, freeing up their time and capacity to focus on clinical issues
- Helping to lower health service utilization and hospital readmissions
- Lowering total cost of care for health systems and payers, while raising quality metrics in value-based care arrangements
Considerations for getting started
A health system can develop a care guidance program through a partnership with an organization that specializes in delivering such services, or if it has sufficient internal resources, a health system may prefer to develop a care guidance program in-house.
In the latter case, although a designated, in-house team member can perform these duties, the care guide role will require a nontraditional approach to care coordination to be able to combine nonclinical interactions with condition-specific symptom assessments.
Launching an in-house care guidance program requires, at a minimum, the following steps:
- Develop a training program for care guides
- Recruit appropriate lay personnel or reassign existing staff
- Define protocols, adopt communications tools and inform team about each
- Implement technology to support care guides in addressing patient challenges
Other key considerations include:
- Availability of professionals with experience and appropriate background to conduct training programs, or costs for recruiting and hiring trainers
- Investment in artificial intelligence (AI) and other IT componentsc
Partnering with a care guide provider offers the advantage of avoiding the initial setup steps and costs, allowing for immediate implementation of care guidance services and ensuring investments in technology keep step with technology developments. A health system with sufficient programming, training, oversight and non-clinical program development resources may prefer to develop its own program with the idea that, after the initial investment, it can enjoy the long-term ability to retain control of the program and absorb it into its operations.
Considerations for developing this function in-house include ensuring that care guides will fit into the hospital’s care processes. In addition to staffing costs, investments will be needed to ensure HIPAA concerns are addressed and to acquire requisite technology, including AI and other IT components.
Benefits under value-based payment
Care guidance programs also can contribute to improved performance and savings for a health system under value-based payment arrangements. The patient-focused nature of a care guidance program can improve patient quality scores and satisfaction metrics while lowering the total cost of care. Such programs also can provide documented feedback from patients on improvements in their physical, financial and emotional well-being and quality of life.
The approach has been demonstrated to improve patient care adherence, reduce readmissions and improve HCAHPS scores. Post-discharge tracking shows that care-guided patients are significantly less likely to require readmission, with significant reductions both overall and in targeted conditions such as those measured under Medicare’s Hospital Readmission Reduction Program (HRRP).
For one large health system, the reduction in unnecessary readmissions attributed to care guidance led to a reduction in HRRP penalties of about 33% in year one, with the penalties almost eliminated after three years, according to an analysis by Guideway Care.
The key to unlocking value from such value-based incentives is in finding better ways to interact with patients — especially outside the clinic walls and in areas of need that may not directly relate to clinical healthcare. Identifying and addressing SDoH has proven essential to qualifying for many of these value incentives. The addition of care guidance builds on quality payment program models, rewarding providers for the quality of care they render based upon standardized value-based metrics.
Key considerations for finance leaders
Although health system finance leaders tend to view investing in care coordination as a financial priority, few can measure and track their actual ROI from such investments. But to justify the investment, they must be able to measure activity, results and patient/caregiver response. When evaluating such an investment finance leaders should keep the following points in mind.
1 Care guidance is not limited to discharge. A care coordination program that is built purely as an extension of the discharge process will be hampered in its ability to gather, address and report on SDoH issues.
2 Care guidance requires a library of support resources to address common barriers to clinical care encountered by patients. Such support resources are needed, for example, to address information gaps, lack of health literacy and confusion about benefits and instructions. Systemized resources also are needed to address practical issues like housing, transportation, financial issues and medication adherence. The effectiveness of programs also depends on awareness of emotional, familial, cultural and spiritual needs, and this consideration is as important as the clinical instruction discharge process.
3 Finding and training individuals with the right qualities and aptitude for these programs is essential. Care guides must be adept at building nonintimidating relationships and at using motivational interviewing techniques to encourage patients to speak about the specific barriers that may be affecting their care journey.
4 Effective reporting is crucial for building internal support for sustainability. Programs must be able to consistently report to stakeholders on care guide performance metrics, including:
- How many issues and barriers have been found
- What percentage of those are clinical
- The impact on follow-up appointment scheduling and attendance
- The extent to which readmissions have been reduced
- Which specific outcomes can be tied to the program
a. Ndugga, N., and Artiga, S., “Disparities in health and healthcare: 5 key questions and answers,” Kaiser Family Foundation, April 21, 2023.
b. Magnan, S., “Social determinants of health 101 for health care: five plus five,” NAM Perspectives. Discussion Paper, National Academy of Medicine, Oct. 9, 2017.
c. According to Salary.com, the average care navigator salary was $55,046 as of March 28, 2023, with a salary range, at that time, falling between $47,215 and $62,955.
d. Becker, C., Zumbrunn., S., Beck, K., et al., “Interventions to improve communication at hospital discharge and rates of readmission: A systematic review and meta-analysis,” JAMA Network Open, Aug. 17, 2021.
The impact of SDoH and why these factors require health system action
Access to high-quality healthcare should not vary because of disparities associated with social determinants of health (SDoH), including race, ethnicity, age, socioeconomic status, place of residence and disability.a
SDoH risks exist not only for individual patients but also for communities, and these risks stem from financial barriers, transportation issues, cultural concerns and other practical matters that tend to fall outside of a health system’s visibility and control.
At-risk patients often require amplified levels of engagement and monitoring beyond a hospital’s capacity to address their whole spectrum of health and wellness. If issues are not resolved, barriers to care can lead to health deterioration, poor outcomes and increased costs.
SDoH impacts on hospital systems
SDoH factors financially impact health systems, particularly for costly, complicated patient medical conditions and care associated with oncology, cardiology, neurology and orthopedics.
The impact of SDoH on hospital readmissions is palpable, disrupting care delivery and being associated with a sizable proportion of healthcare expenditures. Medicare reports that roughly 2 million patients are readmitted each year at a cost of $26 billion, and officials estimate $17 billion of that comes from potentially avoidable readmissions. b
Research also demonstrates that minority and other vulnerable populations are more likely to be readmitted within 30 days of discharge for chronic conditions.c Findings show that while not all readmissions are avoidable, some unplanned readmissions may be prevented by addressing the barriers patients face prior to, during and after admission and discharge.
For more information
See also the sidebar discussions below describing how care guidance can help mitigate nursing shortages and how it aligns with an industry focus on health equity.
a. Fisher, E., et al., “Working across sectors to improve health for older people: the community care connections program,” Health Affairs, Jan. 30, 2020.
b. Healthlink Advisors, “Value-based care approach to reducing readmissions: An enterprisewide care management team sport,” Perspectives, Sept. 28, 2022.
c. CMS, Guide to reducing disparities in readmissions, Revised August 2018.
How care guidance can help mitigate nursing shortages
Nurses are often tasked with addressing SDoH-related issues, including scheduling follow-up visits, ensuring transportation and attending to myriad barriers to care attributed to SDoH.
Care guidance supports clinical nursing teams — freeing up critical time and capacity to focus on clinical issues, which allows nurses to work closer to the top of their license. This approach has been shown to lower total cost of care for payers and to raise quality metrics in value-based payment arrangements. In addition, care guidance provides an innovative solution to clinical staff and resource shortages, maximizing efficiency of hospital nursing teams.
Moving clinical tasks from the day-to-day work of nurses is associated with increased job satisfaction for the nurses who are better able to work on issues for which they trained and which they prefer.a This is where the value of care guidance as an extension of the hospital’s clinical team is fully realized.
a. Yen, P., et al., “Nurses’ time allocation and multitasking of nursing activities: A time motion study,” AMIA Annual Symposium Proceedings, Dec. 5, 2018,
Care guidance aligns with larger industry focus on health equity
The concept of care guidance aligns with other organized efforts to promote health equity. For example, it shares the goals of the newly formed National Alliance to Impact the Social Determinants of Health (NASDOH), a national advocacy organization of healthcare industry stakeholders — both payers and providers — that aims to focus national attention on SDoH to improve health and well-being while reducing long term spending on healthcare.
Care guidance also can enable a health system to achieve optimal HEDIS scores that advance health equity, which payers are tasked with meeting under the new HEDIS Metrics 2023 published by the National Committee for Quality Assurance (NCQA) for Social Need Screening and Intervention. HEDIS-measured performance determines health plan ratings and Medicare Stars Ratings, making it more important in the years ahead for health plans and at-risk provider organizations to resolve member barriers to care associated with SDoH.