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Care guidance helps physician practices achieve health equity


Health equity metrics are increasingly required in value-based care.

Words and phrases like “health disparities”, “social determinants of health (SDoH)” and “health related social needs” have cropped up all over the healthcare spectrum in the last twenty years, but now a new emphasis on actually addressing the root causes that these phrases describe is driving changes to reimbursements and quality metrics. In turn, health equity priorities are impacting the financial and operational performance of physician practices. In many cases, the federal government has led the focus on health equity metrics, such the Centers for Medicare & Medicaid Services’ (CMS) adoption of alternative payment models that give added economic incentives to physician practices, ACOs and IDNs based on health equity objectives.

As the financial success of physician practices is becoming more dependent on meeting new metrics in quality payment programs aimed at equitable patient care, providers are seeking ways to implement health equity programs that will successfully address the socioeconomic conditions of all their patients and optimize reimbursement in value-based care (VBC) arrangements.

Social determinants of health impact health equity

Research into how social, cultural and individualized factors related to motivation, financial resources and health literacy has accelerated, and groups like the American Medical Association (AMA) are encouraging physicians to understand the impact of SDoH on health equity in their patient groups and to work to resolve the barriers they pose to accessing care. SDoH factors include information gaps, personal finances and transportation issues and familial and emotional matters that usually occur outside of the clinical setting or otherwise fall outside of the provider’s focus. Nearly 80 percent of a patient’s risk is tied to SDoH factors unrelated to clinical care. In fact, clinical care accounts for only 10-20 percent of the modifiable contributors to patient outcomes.

Furthermore,patients at-risk of problems embedded in SDoH frequently require amplified levels of activation and monitoring beyond the provider’s traditional focus on clinical care and instructions.

A recent survey from The Physicians Foundation captured additional insights on the degree to which SDoH affect not only patient health as well as physician practices. Similarly, the American Academy of Family Physicians Foundation (AAFP) reported that an overwhelming majority of physicians think (i) SDoH are affecting their patients’ health outcomes, (ii) addressing these drivers is essential to improving health outcomes and decreasing costs and (iii) they will need outside help to overcome the significant barriers to properly addressing all of these issues.

Care guidance is helping tackle practice management challenges

Amid these mounting pressures, more and more physicians are taking a more proactive approach to tackling non-clinical issues associated with SDoH, realizing how important these factors are to the patient journey and to the management of their practices.

Increasingly, providers are looking into non-clinical care guidance as an extension of their clinical team as an efficient way to proactively identify practical issues and resolve non-clinical barriers to care, including those associated with SDoH, such as information gaps, transportation needs, financial concerns and emotional and familial issues that patients commonly experience. Care guidance also ensures that potentially relevant clinical information is escalated to the proper clinical care teams, alleviating time, costs and resource capacity problems, while at the same time enabling clinical staff to focus on clinical issues within their scope of practice and level of licensure. This is where care guidance provides extraordinary value, enabling medical groups to deal with rising operating costs that are fueled by the costs of labor recruitment and retention and the critical nursing shortage. With a properly implemented non-clinical care guidance program, nurses are freed up to focus on clinical issues so they can work at top-of-license, and practices can more effectively address clinician burn-out and associated labor shortages.

Care guidance teams are ideally positioned to work with patients to find and solve non-clinical issues and barriers that lead to non-compliance. By itself, this improves the patient journey and the likelihood of the best clinical outcome. In addition, by using proactive symptom assessments and structured workflows and patient interactions, care guides can find potential clinical deteriorations earlier, and by following pre-defined escalation paths the care guides can ensure that relevant clinical issues are promptly directed to the right member of the clinical team.

How care guidance works

Today’s care guidance programs consist of several components centered on specially selected and trained non-clinical care guides who are tech enabled and provide an essential human touch to supporting patients. When programs are implemented thoughtfully, care guides are equipped to establish deeper personalized relationship with patients and their families and as a result help achieve remarkable outcomes. Serving as the main patient point of contact, this peer-to-patient connection can activate un-motivated patients and lower resistance to them sharing personal information and engaging in the process of their care.

While the human element of care guidance is a key aspect of patient interaction,tech-enabled data intelligence supports care guides with valuable and critical insights. Following structured, AI-assisted workflows, care guides work to identify SDoH factors that pose the most risk to patient care in advance of becoming an issue and barrier to care.

AI and machine learning anticipates patient needs based upon disease and condition-specific protocols that enable care guides to deliver an unprecedented level of vital, just-in-time communications.This supplements patient intake forms and electronic health record (EHR) systems, which are not specifically designed to uncover SDoH issues and facilitate the kind of resolution workflows that are needed when addressing health equity.

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 with reimbursement strategies that incentivizes 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.

These changes are also evident in 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. When care guidance is implemented as a multi-point Solution as a Service model, it also improves CAHPS scores and Medicare Stars Ratings through persistent and consistent patient interactions and active identification and resolution of healthcare barriers related to SDoH.

Care guidance also aligns with the Joint Commission National Patient Safety Goals (NPSG) standards, specifically Goal 16, for improving health care equity. The Joint Commission is taking this action to further elevate the importance of health equity as it impacts healthcare quality and outcomes. As noted at the outset, policymakers and payers have determined that it is no longer sufficient to merely find issues embedded in the SDoH – healthcare providers now must do something to solve those problems.

Value of care guidance for all shareholders

Care guidance is helping physician practices to deliver on health equity priorities through an enhanced patient care experience with lower total cost of care. The addition of a care guidance solution beyond legacy navigation is a truly efficient and effective approach to tackle ‘whole’ person health with tangible and measurable results for decreasing avoidable deterioration and reducing both unnecessary utilization and rehospitalizations.

Nearly thirty years of research has led the way to understanding the importance of addressing all the needs of the patient as a person. As providers respond to accelerating requirements to meet health equity metrics, deploying new patient interaction models can create rapid success and a better, more comprehensive understanding of the patient’s journey. As a result, physician groups can obtain the insight and support they need to deliver quality, equitable care, generate the best possible outcomes for patients and optimize financial and operational performance that meet the expectations of their payer partners.

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

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