What is Care Guidance?
Care guidance is a program of non-clinical interventions that provides patients with support for the whole spectrum of health. Care guidance goes beyond mere patient navigation—bridging gaps in care, creating patient behavioral change, and uncovering and addressing the hidden barriers to care and well-being within social determinants of health.
Why Care Guidance Matters
Health care providers are increasingly answerable for quality metrics that are influenced by what happens outside facility walls, and attempts to address these issues with traditional patient navigation programs or other expensive clinical resources have proven unsustainable. Meanwhile, patients find themselves unequipped to navigate an increasingly complex health care system and struggle to access the resources and support needed to achieve optimal outcomes. Moreover, clinical resources express unhappiness at the huge burden of non-clinical activities they are called upon to perform.
Guideway’s Care Guidance Services
Guideway Care’s care guidance services bridge the gaps patients experience when navigating the health care system, in addition to addressing many non-clinical factors that impact patient outcomes and experience. The program seamlessly embeds within your current workflows as an enhancement to functionality, thereby eliminating unwanted process interruptions. We support and extend your existing clinical resources, improving their efficiency and job satisfaction. Care guidance is delivered through a combination of specially trained and managed care guides, evidence-based protocols, and innovative technology. The person-to-person and technology-enabled interactions are designed to increase patient health literacy, promote patient behavioral change, remove barriers to care, and ultimately improve patient outcomes and satisfaction.
Care Guides
Guideway’s care guides are non-clinical employees hired, trained and managed by Guideway to provide effective, efficient patient support, allowing everyone on the care team to work at the top of their licensure/skill set. Guideway selects care guides using a right fit hiring method and provides extensive training specific to the condition/disease state of the patients with whom the care guide will be working. The care guides are placed within the health system, integrating into your existing care team. Care guides provide support for patients through in-person, phone, and text interactions. Guideway provides ongoing management and training for care guides, ensuring success for the care guides and the patients they support.
Protocols
Guideway’s evidence-based, disease- and condition-specific protocols ensure no one falls through the gaps.
Many existing navigation programs offer a one-size-fits-all approach. Guideway’s care guidance programs are built on evidence-based protocols targeted to each disease state/condition with specific action steps and targeted follow-ups. These protocols ensure that care guides offer proactive, appropriate support, and no one falls through the gaps.
Guideway offers a library of protocols as a starting point, which can be expanded upon and tailored to meet the unique needs of your organization. Some conditions/disease states addressed within Guideway Care’s protocol library include:
- Acute myocardial infarction
- Back or neck procedure
- Amputation
- Atherosclerosis
- Cancer
- Cardiac arrhythmia
- Cellulitis
- Congestive heart failure
- Chronic obstructive pulmonary disease ( COPD ), bronchitis, asthma
- Coronary artery bypass graft (CABG)
- Diabetes
- Fractures of the femur and hip or pelvis
- Gastrointestinal hemorrhage
- Gastrointestinal obstruction
- Identification of and outreach to patients at rising risk for readmission/ED visits
- Implantable cardiac devices (defibrillators, pacemakers)
- Lower extremity/humerus procedure except major joint
- Major bowel procedure
- Major cardiovascular procedure
- Major joint replacement of the lower extremity, including total hip arthroplasty (THA) and total knee arthroplasty (TKA)
- Major joint replacement or revision
- Percutaneous coronary intervention (PCI)
- Pregnancy
- Sepsis
- Simple pneumonia and respiratory infections
- Stroke
- Urinary tract infection
Technology
The Guideway Care technology platform is a
comprehensive care guidance solution, and includes interfaces, predictive analytics, protocols, communications platforms, rules engines and structured reporting, including the ability to solicit, store, and mine patient-reported outcomes. The ability to track activities and see a system-wide view of the patient enables Guideway to offer a program with a proactive, results-driven approach. Guideway’s technology platform helps ensure that patients get the right support at the right time, and helps drive scale for your care guidance efforts.
Guideway also offers a digital health valet that acts as a virtual personal assistant for patients and care guides. The digital health valet provides reminders, prep instructions, education and more via text, helping patients be prepared and empowered in their health care journey, and supporting the care guides’ efforts.
The digital health valet reaches patients with support that is pertinent, relevant and timely. Text interactions reach patients where they are, and are well-received by patients. For example, one site using our communications engine boasts a 99.1% acceptance rate.
The patient told me that he’d had a port placed a month or so prior, but the resident placed it too deep and the infusion nurse was unable to access the port for his treatments. He was discouraged because he had already missed a month’s worth of treatments and, in his words, “could be feeling better by now.”
He’d lost the phone number he needed to call in order to have his port moved, and was having a hard time getting someone to return his call with the information he needed. I messaged the clinical team to let them know about the issue, and by the end of the day, his procedure had been scheduled for the upcoming week with his preferred physician. He sounded relieved when I called to follow up and thanked me for my help!
Morgan S.
Guideway Care Guide
I called a patient after her ER visit. She was still in pain and needed follow-up, but was unsure where to go or who to call because her primary care physician recently retired. She agreed to let me connect her with the hospital schedulers to set her up with a new primary care doctor and we ended up getting her a same-day “establish care” appointment. Normally these appointments are difficult to schedule less than a month out, much less the same day. The patient was clearly excited and said “This is great! I can’t believe I’m getting in so soon.”
Kaleb F.
Guideway Care Guide
One of our COPD patients went to the pulmonologist on Friday for an appointment. During our weekly outreach the following Monday she mentioned that she was depressed and thought she needed medication. She didn’t mention it during the pulmonologist appointment, presumably because she didn’t think it was an issue that they would handle, but the patient opened up to the Care Guide about this issue and likely avoided an ER visit to get help. This shows the power of peer to peer communications with a patient – it amazes me what patients will freely share with the Care Guides that they wouldn’t “bother” a clinician with.
Jennifer M.
Guideway Care Guide
The patient was excited to receive our post visit call, and impressed that [the hospital] would check in with him to see how he was doing. He said that he had never experienced such professional care before, thanked me repeatedly for calling, and told me it truly made a difference in his day.
Katelyn E.
Guideway Care Guide
I was on the phone with a patient who had been experiencing some depression due to recent events. He stated he felt okay and didn’t need anything. We hung up and 5 minutes later my phone rang. It was his daughter. She heard the phone call and wanted to let me know that her father did need some assistance with his mental health and that she was concerned about his depression. I escalated to the clinical staff and we were able to work with his daughter to get him to the hospital for evaluation.
Jennifer M.
Guideway Care Guide
One patient I called was due for his Annual Wellness Visit. I called the doctor’s office and was able to get the patient scheduled. At that point, the patient was very open to speaking with me and mentioned that he was alone, could barely see, and could not hear well. He mentioned that he felt alone and our conversation was the “highlight of his day.” I let the patient know if he had any concerns or questions to call me and I would be glad to help.
Whitney O.
Guideway Care Guide
I was speaking with one of our elderly patients during our weekly outreach. She told me that she recently moved to the city to be closer to her son, but that she didn’t have any friends or social support since moving. She said she was starting to feel lonely and depressed. We discussed this patient during our weekly case review meeting and agreed that the geriatric clinic would be a good resource for her. We got her connected with this group so they could connect her with resources and monitor her more closely. The next time I spoke with her she stated that she really felt cared for and knew that we were looking out for her.
Jennifer M.
Guideway Care Guide
I made a post-ER call to a patient. She was irritable because she was in a great deal of pain, and mentioned that her follow-up visit with her PCP wasn’t scheduled for several more weeks. I explained the importance of scheduling a follow-up visit within 2 weeks after being in the ER. She put her husband on the line, who explained that they had just called that morning and were told that she couldn’t be seen for several more weeks. I asked if I could assist them with getting in faster. The patient agreed and after completing her survey, we were able to get the PCP appointment moved up. She thanked me over and over again for caring and not reflecting her tone or mood.
Whitney O.
Guideway Care Guide
I called a patient for their post-visit survey and the patient immediately said that her visit to the ED was not a good experience. The patient complained about the wait time and being put in 3 different triage rooms. I empathized with the patient and also educated her on the benefits of using an urgent care clinic vs. the ED. During the survey, she mentioned that she had a question about her diet. I escalated her concern up to the nursing pool, and they responded within the same hour. I followed up with the patient and she thanked me for my help and kindness. The best part is that at the end of the call, the patient said, “It feels good to know that [the hospital] cares about me, and if I need anything else I have your number and I have someone to call.”
Whitney O.
Guideway Care Guide
I called a patient as part of the transition at the end of their follow-up period. He and his wife were both on the phone; the wife said that she was really confused about what medication to give him and when. I escalated her concerns to the nurse, who walked them both through his medications. The wife said that she felt much more confident about being able to care for him correctly.
Jennifer M.
Guideway Care Guide
I had an out of state patient who had no PCP. He was actively looking to be established with a PCP and had been having no luck at all. I researched primary care physicians where he lived to give him a couple of options. He picked a location and doctor and I was able to get an appointment scheduled with them. The patient was very appreciative. He said that he had never received such great patient care before.
Katelyn E.
Guideway Care Guide
I’d been doing the weekly outreach calls to a high ED utilizer, asking him about his COPD symptoms to help him track them. One of the questions asked weekly is “How far can you walk before running out of breath?” By the fifth week, he told me he had started walking around his neighborhood more to test out how far he can go. He specifically mentioned my calls as a motivating factor for this. He said he was surprised by his ability, and over the next few weeks he continued his walks. It’s satisfying to know that what we do influences patients towards positive behavioral changes.
Kaleb F.
Guideway Care Guide
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