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    Craig Parker
    Craig Parker, JD, CPA

    Care guidanceWhen MGMA published a survey nearly 10 years ago, the results revealed major challenges to running a group practice, many of which persist today: 

    1. Dealing with rising operating costs
    2. Preparing for reimbursement models that place greater financial risk on the practice
    3. Managing finances with the uncertainty of Medicare reimbursement rates.1

    These issues were exacerbated by the introduction of new quality payment models that tie physician reimbursement to capabilities for resolving social determinants of health (SDoH) and advancing the goals of health equity.2 There’s broad agreement that access to healthcare and outcomes of clinical interventions can be improved by ending patient disparities associated with SDoH.3 However, little progress has been made on this front over the past decade, and now the government and payers are taking steps to force acceleration.

    For example, the Centers for Medicare & Medicaid Services (CMS) introduced an array of Quality Payment Programs (QPP) as a value component to the accountable care organization (ACO) model which offers shared savings to groups that deliver coordinated, high-quality care to Medicare patients. Additionally, the newly designed ACO Realizing Equity, Access and Community Health (ACO REACH) model introduces an innovative payment approach requiring all model participants develop and implement a robust health equity plan to identify underserved communities and implement initiatives to measurably reduce health disparities within their beneficiary populations.

    Moreover, the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) give added incentive payments to providers that achieve high scores for high-quality, cost-efficient care that attains the highest level of health for all people.

    The adoption of a care guidance solution is a natural extension of QPP models, unlocking value from these incentive-based contracts by identifying better ways to interact with patients, overcome challenges of SDoH and improve outcomes. 

    Impact of nonclinical issues

    Amid mounting pressures and growing awareness of factors impacting the patient journey, medical groups are now starting to take a more proactive approach to resolving nonclinical issues and SDoH. Clinical care is estimated to account for only 10% to 20% of the modifiable contributors to a patient’s well-being and healthy outcomes for a population. The other 80% to 90% are considered nonclinical SDoH issues that may pose barriers to care.4 Unfortunately, SDoH risks primarily center on financial barriers, transportation issues and other practical matters that usually occur outside of the clinical setting or otherwise fall outside of the provider’s clinical focus.

    In a study published by JAMA,5 researchers examined the Patient Care Connect Program6 compared with matched comparison patients; their results showed that nonclinical navigation programs should be expanded as health systems transition to value-based care (VBC). For example, readmissions data on matched populations following an index admission indicate that patients who were in the care guidance program (a form of patient activation beyond mere engagement) were significantly less likely to require readmission,7 with significant reductions in utilization among acute and targeted conditions.8

    Furthermore, post-discharge tracking has demonstrated that care-guided patients better understand their discharge instructions, are more likely to follow clinical instructions, are more satisfied with the in-patient experience, and are more likely to recommend their care providers.9 At-risk patients often require these amplified levels of activation and monitoring beyond the provider’s capacity to address the whole spectrum of health and wellness. However, addressing whole-person health is exactly what is required to achieve superior outcomes and financial performance.

    Care guidance is also an opportunity to better identify and solve a wider breadth of nonclinical issues impacting patients, as SDoH encompasses many risks and impediments that impact a patient’s ability to comply with clinical instructions and stay on track.

    Case example of care guidance

    Medical practice serving Medicaid population: Care guides were deployed to rapidly assist a Medicaid provider in explaining care options and benefits to patients and their caregivers. By decompressing the conversation and utilizing peer-to-peer communication, care guides were able to increase enrollment and access options for under-resourced families. These activities favorably positioned the provider with a large payer and established a collaborative relationship for sign-up and utilization challenges to increase participation. 

    How care guidance works

    Today’s care guidance programs consist of several components, including specially selected and trained lay care guides who are equipped with technology platforms that provide structured workflows and which use evidence-based disease and condition-specific protocols.

    Care guidance proactively identifies and resolves at-risk patient issues through personalized care navigation and technical innovation, optimizing the experience and resolving barriers associated with SDoH. Care guides establish a deep, personalized and ongoing relationship with patients and their families by serving as the main patient point of contact; the peer-to-patient connection can lower resistance to sharing personal information and provide individuals with the guidance they need to act and engage in the process of their care journey.

    Capture SDoH data and gain strategic insight

    An effective care guidance platform becomes crucial for capturing SDoH data and disparity-related barrier resolution. It is a platform that facilitates operational improvement by seamlessly escalating clinically relevant information while delivering SDoH insights for each patient population. This specialized platform supplements the capabilities of EHR systems, some of which are not specifically designed to facilitate the kind of resolution workflows that are needed when addressing health equity and social determinant issues.

    Structured, AI-assisted workflow protocols are used in care guidance to guide patient interactions in ways that help identify SDoH factors that pose the most risk to patient care outcomes. Crucially, while administering SDoH and health related social needs screenings, care guides conduct routine symptom assessments that can identify potential indicators of clinical deterioration earlier.

    When potential deteriorations are identified (according to thresholds set by clinical teams), these clinical risks are escalated to proper clinical care teams. In an integrated care guidance delivery system, escalations can be automatically messaged to clinical teams in the electronic health record system where they are used to working. Data analytics also provide non-clinical insight into demographics that might fit the patient and as a result facilitate communication. AI and machine learning anticipates patient needs based upon condition-specific protocols that enable care guides to deliver an unprecedented level of vital, just-in-time communications.

    The human element of care guidance provides optimal value when care guides are supported by data intelligence, enabling them to provide patients with the information they need to engage in the process of their care and receive a better understanding of their treatment plan and options.

    Case examples of care guidance

    • Medical practice and clinical trials: Care guides were used to increase accrual and retention rates in oncology clinical trials and in this case, the use of care guides was determined to increase accrual rates from 11% of a targeted population to 22% over a two-year period. Care guidance strengthened patient engagement and led to improved adherence and compliance with all aspects of activity under the specified clinical trials.
    • Northern California “payvider” practice: In a use case where care guides were deployed to decrease avoidable utilization by increasing screenings and annual wellness visits, the program achieved a more than 20% increase in annual wellness visits attended by finding and resolving barriers that impacted appointment attendance. Care guidance measurably advanced preventive care, helping the practice to boost efforts for reducing hospitalizations, avoiding costly interventions and achieving better outcomes — the pillars of value-based care contracts.

    An extension of the clinical team

    Nonclinical care guidance supports provider groups as an extension of the clinical team, freeing up critical time and resource capacity. This solution enables medical groups to deal with rising operating costs that are fueled by the chronic, expensive costs of labor recruitment and retention and the critical nursing shortage.10 As a result, nurses can focus on clinical issues and work at top-of-license.

    The care guidance team is ideally positioned to work with patients to find and solve nonclinical issues that lead to nonadherence to treatment plans.11 Care guides define and follow escalation paths to ensure that relevant clinical issues are directed to the right member of the clinical team — promptly and with the right amount of triage information.

    Care guidance supports equitable care goals

    Policymakers, regulators and payers play a critical role in setting standards for measuring the efficacy of health equity initiatives with reimbursement strategies that incentivizes equitable care. The newly formed National Alliance to Impact the Social Determinants of Health (NASDOH), a national advocacy organization of healthcare industry stakeholders, aims to focus national attention on SDoH to improve health and well-being while reducing long-term spending.

    These changes are also evident in the Social Need Screening and Intervention (SNS-E) HEDIS metrics requirements published by the National Committee for Quality Assurance (NCQA). According to NCQA leaders, these new measures are part of an organization-wide effort to advance health equity and encourage providers and health plans to assess and address the food, housing and transportation needs of populations.12 When care guidance is implemented as a multi-point Solution as a Service model, it is designed to help improve CAHPS scores and Medicare Stars Ratings through persistent and consistent patient interactions and the active identification and resolution of healthcare barriers related to SDoH.

    Finally, care guidance aligns with Joint Commission National Patient Safety Goals (NPSG) standards, specifically Goal 16 for improving health care equity.13 The Joint Commission is taking this action to further elevate the importance of health equity as it impacts healthcare quality and outcomes. It is no longer sufficient to merely find issues embedded in the SDoH – healthcare leaders now must do something to solve those problems.


    1. “Survey: 5 Biggest Challenges of Running a Medical Group Practice.” Becker’s Hospital Review. June 25, 2013. Available from:
    2. Office of Disease Prevention and Health Promotion. “Social Determinants of Health.” HHS. Available from:
    3. Artiga S, Orgera K, Pham O. “Disparities in Health and Health Care: Five Key Questions and Answers.” Henry J. Kaiser Family Foundation. March 2020. Available from:
    4. Hood CM, Gennuso KP, Swain GR, Catlin BB. “County health rankings: Relationships between determinant factors and health outcomes.” American Journal of Preventive Medicine. 2016;50(2):129-135.
    5. Rocque GB, Pisu M, Jackson BE, et al. “Resource Use and Medicare Costs During Lay Navigation for Geriatric Patients With Cancer.” JAMA Oncol. 2017;3(6):817–825. doi:10.1001/jamaoncol.2016.6307.
    6. Rocque GB, Partridge EE, Pisu M, Martin MY, Demark-Wahnefried W, Acemgil A, Kenzik K, Kvale EA, Meneses K, Li X, Li Y, Halilova KI, Jackson BE, Chambless C, Lisovicz N, Fouad M, Taylor RA. “The Patient Care Connect Program: Transforming Health Care Through Lay Navigation.” J Oncol Pract. 2016 Jun;12(6):e633-42. doi: 10.1200/JOP.2015.008896. Epub 2016 May 10. PMID: 27165489; PMCID: PMC5702802.
    7. Benbassat J, Taragin M. Hospital Readmissions as a Measure of Quality of Health Care: Advantages and Limitations. Arch Intern Med. 2000;160(8):1074–1081. doi:10.1001/archinte.160.8.1074.
    8. Bakshi S, Carlson LC, Gulla J, Wang P, Helscel K, Yun BJ, Vogeli C, Flaster AO. “Improving Care Coordination and Reducing ED Utilization Through Patient Navigation.” Am J Manag Care. 2022;28(5):201-206. doi: 10.37765/ajmc.2022.89140.
    9. Guideway Care. “5 Top Reasons Hospital Readmissions Happen: And How to Prevent Them.” Sept. 22, 2022. Available from:
    10. American Association of Colleges of Nursing. “Nursing Shortage.” Available from:
    11. Kleinsinger F. “Working with the noncompliant patient.” Perm J. 2010 Spring;14(1):54-60. doi: 10.7812/TPP/09-064. PMID: 20740133; PMCID: PMC2912714.
    12. NCQA. “NCQA Updates & Releases New Quality Measures for HEDIS® 2023 with a Focus on Health Equity.” Aug. 1, 2022. Available from:
    13. The Joint Commission. “Infection Prevention and Control.” Available from:
    Craig Parker

    Written By

    Craig Parker, JD, CPA

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