Data analytics within the platform provide insight into non-clinical issues, identify probable SDoH risks and facilitate personalized communication. By gathering condition- and journey-specific data on thousands of patients, a care guidance platform can take advantage of machine learning to anticipate patient needs based upon condition-specific protocols that enable care guides to deliver an unprecedented level of vital, just-in-time communication.

This is different than AI, which is not likely to be successful in facilitating this kind of patient activation unless the AI tool can be trained using the thousands and thousands of journey-specific data points – which don’t actually exist in large EHR systems. Taking advantage of machine learning insights, care guides provide patients with the information they need to engage in the process of their care and empower each consumer to receive a better understanding of the treatment plan and options.


Achieving success in quality payment programs
A growing number of providers are electing to participate in value-based care 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 as a value component to the Accountable Care Organization model.

There are many options for providers to explore participation in CMS programs. Care guidance support to supplement clinical protocols with social determinants efforts pave the road to successful contracting. No matter which programs a provider is considering, the common element is the need to better identify, document and resolve barriers embedded in social determinants and drivers of disparities, initiatives that advance health equity for all patient populations.

The Bottom-line benefits of outsourced care guidance
The addition of a care guidance program beyond mere navigation efforts provides a unique solution-as-a-service. Collaboration between hospitals, providers and care guidance teams supports a triad of care coordination and management. Hospitals and their clinical staff receive the extended support they need from a dedicated care guidance service:

• Reaching and managing more patients, maintaining their continuity of care.
• Removing non-clinical tasks from the workloads of nurses and clinical staff.
• Performing follow-ups and monitoring, conducting follow-up tasks and ensuring that potential issues and barriers are proactively identified and resolved.

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