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Guideway Care is Your One Solution for Evidence-Based Patient Activation

Improve Financial and Clinical Outcomes Across the Enterprise

Guideway Care is Your One Solution for Evidence-Based Patient Activation

Improve Financial and Clinical Outcomes Across the Enterprise
Readmissions

Evidence-Based Patient Activation Solution for Readmissions Challenges

One Solution. One Focus. We are the Activation Company. At Guideway Care we do one thing extremely well—we activate patients, ensuring they take the next right step, no matter the challenge, including with Readmissions issues.

Reduce avoidable returns—one next step at a time.

For 30 days after discharge, Guideway engages patients by phone and SMS to spot risks early and remove barriers that drive readmissions. Our AI-driven, science-backed activation platform blends Activation Psychology with each patient’s real-world constraints and motivators, giving Activation Care Guides real-time guidance to prompt the right next step—every time.

What we do over 30 days:

Identify and address early, condition-specific warning signs
Conduct regular check-ins to surface escalating symptoms or barriers
Verify medication adherence and ensure prescriptions are filled and taken as directed
Schedule and confirm attendance at post-discharge follow-ups
Confirm understanding and compliance with discharge instructions
Uncover and resolve SDOH/logistical barriers impacting recovery
Close care-coordination gaps, including specialist referrals and network navigation

Benefits

  • Reduction in 30-day readmissions
  • Reduction in ER Utilization
  • Reduction in HRRP penalty liabilities
  • Decrease in uncompensated or low-margin readmissions
  • Creation of additional inpatient bed capacity for high-margin procedures
  • Optimization of downstream specialty referrals
  • Reduction in missed follow-up appointments
  • Increase in patient satisfaction scores
  • Minimization of patient leakage rates
  • Strengthening of care-transition workflows
  • Improvement in medication adherence rates
  • Better post-discharge adherence treatment plans
  • Enhancement of value-based reimbursement
  • Actionable insights on readmissions prompt operational efficiency with the discharge team

Frequently Asked Questions

What is patient activation and how does it help reduce readmissions?
Patient activation refers to engaging and empowering patients to take an active role in their own care journey—understanding their health needs, following care plans, and overcoming barriers to treatment. Guideway Care’s Evidence-Based Patient Activation model uses behavioral science-informed outreach to help patients navigate challenges such as medication access, follow-up appointments, or understanding discharge instructions. By removing these obstacles, patients are more likely to recover successfully at home, reducing the risk of being readmitted.
How does Guideway Care address non-clinical factors that lead to readmissions?
Many readmissions are driven by non-clinical issues—transportation gaps, food insecurity, lack of social support, or confusion about care instructions. Guideway Care’s specially trained Care Guides identify and address these root causes through proactive outreach and personalized support. By solving these barriers before they escalate into a medical crisis, we help hospitals and health systems reduce readmission rates and improve overall patient outcomes.
Can Guideway Care work alongside existing care coordination teams?
Yes. Guideway Care’s model is designed to complement—not replace—existing clinical teams. Care Guides focus on the non-clinical, behavioral, and social drivers of health, freeing clinical staff to focus on medical care. We integrate seamlessly with hospital workflows and electronic health record systems, ensuring that both clinical and non-clinical interventions are aligned to keep patients on track after discharge.
How quickly does patient activation begin after discharge?
Timeliness is critical in preventing readmissions. Guideway Care initiates patient activation within 24–48 hours after discharge, when patients are most at risk of confusion, missed medications, or lapses in follow-up care. Early outreach allows us to address questions, confirm care plan understanding, and connect patients with needed resources before issues escalate.
What results have health systems seen from using Guideway Care to reduce readmissions?
Health systems partnering with Guideway Care have achieved measurable reductions in avoidable readmissions—often in high-risk populations where traditional approaches have struggled. Our approach improves patient satisfaction, supports compliance with value-based care goals, and protects hospital revenue under readmission penalty programs. Each implementation is tailored, but our consistent success comes from addressing the non-clinical factors that frequently undermine recovery.