Care Navigation Using Non-Clinical & Clinical Protocols

Resolving Patient Barriers Drives Patient Satisfaction and Financial Performance.

Case Study Snapshot

  • Client
    Large Non-Profit Healthcare System
  • Program
    HRRP, HCAHPS
  • Year
    2020
  • Size
    535 Beds
  • Location
    Arizona
  • The Challenge
    Reducing Readmissions
  • The Solution
    Patient Care Guidance
  • The Success
    33% Reduction in HRRP Penalties

The Challenge

Reducing Readmissions and Improving HCAHPS

A large non-profit health system operating two hospital systems and ancillary care facilities in Arizona aimed to both reduce readmissions among vulnerable patients discharged under the Hospital Readmissions Reduction Program, as well as to drive higher patient satisfaction amongst all discharged patients. Studies indicate that readmission risks are higher for patients facing certain socioeconomic characteristics, particularly for costly and complicated medical conditions.

These characteristics include Social Determinants of Health (SDoH) such as race, ethnicity, language proficiency, age, socioeconomic status, place of residence and disability.

Nurses reported that up to 80% of their workload was dedicated to non-clinical, practical barriers.

The Solution

Patient Activation

Guideway Care utilizes highly trained “Care Guides” who proactively engage with patients and their families to build peer-to-patient relationships. Operating within the Guideway platform the non-clinical Care Guides uncover issues and barriers related to both non-clinical and clinical needs. Care Guides follow structured, AI-assisted workflow protocols and assessments. Care Guides resolve non-clinical barriers and escalate clinical barriers and condition deterioration to clinical teams.

This is where the value of Care Guides as an extension of the hospital’s clinical team is fully realized.

The Success

Improving Financial Performance and Patient Satisfaction

The use of Care Guides was validated by improved care adherence, reduced readmissions, and improved HCAHPS scores. Care Guided index stays indicated that patients were significantly less likely to require readmission, revealing significant reductions in six of seven targeted conditions. It is important to note that this is a true comparison, between both the Guided and non-Guided populations, for discharges that were coded into the qualifying condition.

Care Guides also provided an innovative solution to clinical staff and resource shortages, maximizing efficiency of hospital nursing teams. This alleviation reduced associated operating costs while freeing up nursing capacity to focus on high-value, clinical work. Nurses reported that up to 80% of their workload was dedicated to non-clinical, practical barriers. This is where the value of Care Guides as an extension of the hospital’s clinical team is fully realized.