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Care guidance programs can boost chronic care management efforts


Care guidance builds stronger connections with patients and drives better health outcomes

Tina Graham, COO, Guideway Care: ©Guideway Care

Tina Graham, COO, Guideway Care: ©Guideway Care

Chronic Care Management (CCM) represents an important connection point between providers and their vulnerable patients. Individuals who are at-risk for health-related social needs and other disparities typically require higher levels of interaction, support and monitoring to achieve the amplified levels of activation that are necessary to achieve the best possible outcomes for these patients. However, this level of interaction, support and monitoring challenge the already thin resource capacity of health care organizations.

Addressing the whole spectrum of a patient’s condition

There is growing recognition of the struggles CCM patients face to overcome disparities attributed to social determinants of health (SDoH). These are the non-clinical conditions in patients’ daily lives that affect a wide range of their everyday functions, and typically fall outside of a hospital’s visibility and control. SDoH are categorized by socioeconomic, education, cultural, and environmental domains that are shown to perpetuate health disparities and widen health inequities among patients, especially affecting those with chronic health conditions.

Nearly 80% of a patient’s overall health and outcomes are tied to socioeconomic factors. Left unresolved, non-clinical issues can pose barriers to care delivery and transitions, treatment adherence and medication compliance and hinder a patient’s ability to perform self-care, potentially leading to further health deteriorations and rehospitalizations. These outcomes financially burden hospital operations and complicate CCM.

Care guidance solution

Many health care provider organizations are finding value in employing patient advocates and navigators whose scope is focused on proactively activating CCM patients and identifying and resolving their disparities - before they become clinically problematic and costly. However, nearly all organizations that have tried to leverage “lay” personnel to support and extend the clinical team have found that success care navigation programs require careful thought about roles and responsibilities, additional technology investments to support scalable and repeatable non-clinical workflows and specialized training and supervision for these extender resources.

A well-designed care guidance program extends the capabilities of a clinical team and advanced the priory and goals of improving quality and advancing health equity in managed care and value-based arrangements. When applied in support of CCM, care guidance provides a significant upside for providers, patients and payers.


A systematic review observed that patients with chronic diseases experience barriers to managing their diseases and accessing available health services. The investigators recognized that patient guided programs are increasingly being used to help patients with chronic diseases navigate and access health services. Findings indicate that these programs improve processes of care, clinical outcomes and reduce costs.

According to a policy brief issued by a partner of the World Health Organization (WHO), there are rising rates of chronic diseases, long-term conditions, and multimorbidity, with patient health care needs becoming increasingly diverse and complex. As a result, vulnerable patients who experience chronic conditions may require various types of non-clinical service and social care. These patients repeatedly have to transition between inpatient and ambulatory care, as well as between different providers, and often need support in coordinating their care.

How care guidance works

The addition of a care guidance program, beyond legacy navigation, provides health care organizations with truly effective support service by freeing up labor, time, and resources so that clinical staff can focus on high-value tasks within their scope.

The success of a care guidance program rests largely on 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, enhances a patient’s ability to communicate and helps to uncover issues that pose barriers to care. The support of care guides then works to resolve these issues and assist patients in the ongoing process of their care.

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 practical and non-clinical barriers experienced during their care. With this technology support, care guides ensure that non-clinical issues get promptly resolved, and clinical issues are immediately escalated to proper clinical care teams.

The human element of care guidance is important as automated technology cannot be a replacement for the human aspect of patient interaction. This is especially true considering the limited abilities certain populations have in accessing digital health technologies and potential use impairments among disabled, disadvantaged, and senior populations. The right mix of human and tech elements, integrated together, support personalized and meaningful peer-to-patient relationships and personalized communication in providing patients and their families with the connected support they need to stay on track and engage in the management of their condition throughout their care continuum.

Capture strategic insights

An effective care guidance platform captures SDoH data and disparity-related barrier resolutions that help operational improvement and supplement electronic health records systems, some of which are not specifically designed to facilitate the kind of workflows that are needed when addressing health equity and social determinant issues.

Upon intake, care guides personally conduct an assessment to identify and address and the patient’s social needs and concerns. Data from these screenings provide key insights to identify probable SDoH risks. Led by this intelligence, care guides proactively and promptly resolve non-clinical issues. In an integrated care guidance delivery system, clinical issues are promptly escalated and automatically messaged to clinical teams.

New revenue opportunities

Since the introduction of reimbursement for CCM, the Centers for Medicare & Medicaid Services has consistently increased payments rates to advance this important aspect of connected care for patients experiencing multiple complex conditions.

CCM programs have the ability to garner additional revenue streams. CPTÒ code 99490 covers non-complex CCM, paying an average reimbursement rate for 20-minutes of CCM service provided by clinical staff (per patient per month) to coordinate care across providers. Providers are also permitted to bill CPT code 99439 up to two times (per patient per month) as an add on code, paying a reimbursement rate for each additional 20 minutes of CCM service provided by clinical staff.

Care guidance programs support a range of additional care management models, including:

  • Principal Care Management (PCM)
  • Annual Wellness Visit (AWV)
  • Remote Patient Management (RPM)
  • Total Care Management (TCM)

A growing number of providers are electing to participate in arrangements that link payments to measured health equity improvements and overall quality performance indicators. A CMS initiative that is helping advance health equity is the introduction of the Quality Payment Program (QPP) as a value component to the Accountable Care Organization (ACO) model.

For providers that are exploring options to participate in these programs with the support of care guidance to supplement clinical protocols with social determinants efforts, there are a number of choices. No matter which program a provider is considering, the common element is the need to better identify, document and resolve barriers embedded in SDoH and drivers of disparities, and advance health equity for all patient populations.

Value of a care guidance partnership

Care guidance is becoming a “must-have” addition to the service line portfolio of health systems, hospitals, and provider organizations. It is at the nexus of CCM and managed care priorities where care guidance represents an innovative approach to connected care, advancing heath equity and delivering high-value, high-quality care. A partnership with an outsourced care guidance portfolio of services can be an effective strategy, however, attempting to allocate internal resources to perform the tasks that fall within the scope of care guides could potentially be both inefficient and costly.

An outsourced care guidance program that is scaled and well-designed offers a truly cost and time effective connected care solution. Providers receive extended clinical and non-clinical support in the context the “Triple Aim” of improving the care experience, advancing population health and reducing total cost of care. Patients receive equitable and personalized care; clinical staffs are freed to focus on the tasks within their scope, and hospital administrators have an opportunity to improve financial and operational performance. This is where care guidance presents the most value to all shareholders.

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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