By Greer Myers, President, Guideway Care

In the quest to provide every Tennessee resident the opportunity to live a healthy life, it appears that despite Tennessee's thriving healthcare industry, not all Tennesseans have access to quality and affordable health care. Conditions in the places where Tennessee residents live, learn, work and play affect a wide range of health risks and outcomes.

These conditions are known as Social Determinants of Health (SDOH). Improving health disparities associated with SDoH reduces risks of unnecessary utilization, health care costs and achieves better outcomes. Integrating and aligning care solutions with state and regional hospitals and community-based partners and providers has the potential to improve the health as well as lowering care management expenses and total cost of care.

Unfortunately, there are communities in Tennessee with inadequate housing, low household incomes, or lack of access to healthy food where residents may be at risk of poor health outcomes. Applying research on social determinants and introducing innovative approaches to care that address these issues can improve health and well-being for Tennessee's residents.

 Source: Tennessee Department of Health

Health Equity for Tennesseans

According to the Tennessee Department of Health, health disparities affect many populations throughout the State, including Native American, Black and African American, Hispanic and Latino, the disabled, low-income, less educated and people who live in rural areas. Communities with unstable housing, low income, unsafe neighborhoods or substandard education are more also likely have health disparities. 

Health disparities affect many residents throughout Tennessee who find inequities to accessing basic health. This also applies to preventative care and ongoing care to treat chronic conditions. One significant factor is that low-income immigrants and those with limited English proficiency face unique barriers in accessing health care. Despite having the fastest growing immigrant population in the country, service providers in Tennessee often lack cultural awareness and language sensitivity. Safety-net clinics are under-capacity and struggle to coordinate care.

Tennessee Health outcome ranks displayed using quartiles (map) and underlying health outcome scores (chart):

Source: 2022 Tennessee State Report

Health equity not only strengthens the fabric of communities, but also grows the State’s economic position. Diminishing the incidence and progression of diseases impacts individual productivity and yields a healthier workforce. Communities that understand and respond to health disparities benefit both individual and population health.

Introducing an Innovative Approach:

Care Guides Resolve SDoH and Barriers to Care

Throughout the country and now in Tennessee, vendor-partner relationships with hospitals, health systems, payers and provider organizations can positively impact patient lives, activating patient behaviors to enhance health outcomes and concurrently drive financial and operational improvements in Value-Based Care. Utilizing trained non-clinical resources, such as Care Guides, to work with patients and caregivers to understand and resolve their issues and barriers to care can result in a uniform care experience and optimal outcomes.

Essentially, Care Guides extend health system’s clinical care team, reaching patients beyond facility walls. Effective care guidance requires collaboration with like-minded partners that are dedicated to improving health equity and welfare for their entire community.

Trained and focused Care Guides establish a connected relationship with patients and their families. Serving as the main patient point of contact, this peer-to-patient connection lowers patient resistance to sharing personal information and provides individuals with the guidance they need to act and engage in the process of their care.

Care Guides create patient behavioral change, uncovering and addressing barriers hidden within SDoH, as well as bridging gaps patients experience within their journey of care.

A good care guidance program includes several components, including specially trained and managed Care Guides, evidence-based disease and condition-specific protocols, as well as a comprehensive care guidance technology platform. To ensure smooth operations, the process begins with an Action Gap Assessment, which evaluates the preparedness of a health system to implement personalized patient engagement and make sure the organization is prepared to deliver the proper care protocols for the best experiences.

Tech-Enabled Approach

A well-designed platform guides and informs the Care Guides to resolve non-clinical patient issues that become barriers to care or automate the escalation of clinical patient barriers to the clinical teams in place. That approach allows the organization to capture data for required reporting and conduct quality improvement activities.

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 human communications. Led by this intelligence, Care Guides provide individuals with the information they need to engage in the process of their care – to activate behavioral changes. As a result, patients have a better understanding of their care transitions.

The high-tech capabilities are driving the human touch, which results in highly structured and protocolized peer-to-patient interaction. While analytics can identify probable risk and technology can facilitate communication, neither can establish the needed personalized, peer-to-patient relationship, as provided by Care Guides, that leads to real, meaningful patient activation and barrier resolution.

Validating Results

Tennessee is not ranked highly regarding healthcare when compared to other states. One report has it ranked 44th based on cost, access and outcomes. Another study has it ranked 40th overall based on access, quality and public health.

However, one Tennessee-based health system, sought to reduce unnecessary readmissions, improve care coordination and enhance patient engagement and experience to improve performance under the Hospital Readmissions Reduction Program (HRRP).

Improvements attributed to their Care Guide program were measured by value-based metrics validating the role of non-clinical interventions in reducing unnecessary utilization, improving patient care adherence, advancing health equity and enhancing patient experience. Readmissions were decreased by 32%, among five specific DX conditions.

Nurses with this hospital report that up to 70% of their workload is dedicated to non-clinical, practical tasks that only address the bare minimum of SDoH, which is outside of the hospital’s visibility and control. Care Guides effectively addressed SDoH and effectively relieved the burdens on nurses and clinicians.

The benefits are felt throughout health care organizations such as the Tennessee-based health system referenced above. Freed from practical, non-clinical tasks, high-value nursing staff can focus on clinical work. These health systems also regard Care Guides as an important part of their organization’s efforts to improve their HCAHPS scores -- the first national, standardized, publicly reported survey of patients' perspectives of hospital care. Furthermore, health systems enjoy reduced and even eliminated readmission penalties as well as a strengthened reputation in their community.

Guiding the Future of Health Care

Having a vendor-partner act as an extension of existing clinical teams makes health equity actionable and benefits the patient, member and healthcare organization. It allows nurses and physicians to operate at the highest level of their license, lowers operating expense, decreases acute care utilization, alleviates clinical staffing shortages. The validated results of care guidance are paving this exciting journey to better health outcomes as well as improved hospital and health system financial performance in the transition to Value-Based Care.

Greer Myers is President of Guideway Care. For more than a decade, partnering with hospitals, health systems, payers and provider organizations, Guideway positively impacts patient and member lives, while improving financial and operational performance for our client partners. Specifically selected and highly trained non-clinical Care Guides, utilizing Guideway’s proprietary technology platform, build peer-to-patient relationships to uncover and resolve non-clinical and clinical barriers to care though patient activation, resulting in a uniform care experience and optimal outcomes. www.guidewaycare.com