Dedicated clinical guide: who they are how they increase benefits utilization.

The rise in healthcare complexity has created a surge in demand for healthcare navigation, a set of services that help patients manage their healthcare needs, improve their healthcare experience, and lower their costs. The services that fall under healthcare navigation and how they’re delivered range widely, from glorified chatbots that help members access basic help (like seeing their co-pay), to clinicians working one-on-one with members to navigate highly complex healthcare needs, like oncology care. The names for who is rendering these services vary widely, too. They include health guides, healthcare advocates, and healthcare navigators, among many others.

Some consumers are so starved for help navigating the complex system, they will welcome any kind of healthcare support, no matter how basic. The reality is, however, that low-touch solutions powered by bots or call centers provide such rudimentary support, they don’t meaningfully improve the consumer’s healthcare experience and fail to move the needle in providing healthcare value and improving health outcomes.

Who is a health guide?

Today, services that call themselves ‘care navigation solutions’ are rendered by both humans and bots as well as clinical and non-clinical experts. While one can argue that all these services assist members in some capacity of navigating healthcare, health guides who engage in effective, high-touch care navigation must have the following qualities: 

• They must be human. 

Consumers are already disillusioned with healthcare; the complex nature of the landscape and the disparate data does not lend itself well to bot assistance. Speaking with a human lets members feel heard and allows them to establish an ongoing relationship with their dedicated health guide that builds trust. This is a key component of changing member behaviors and ensuring they continue to utilize care navigation services.

• They must be clinical.

Having dedicated clinical guides is key – they can perform the right triage to understand the true need of the member and offer the right set of actions for the member to take. Oftentimes, consumers don’t even know the questions they need to ask to get to the care they need. But a nurse does – when a member opens up, they can help them make the right decision at the right time, maximizing their impact.

• They must be available on demand to answer questions and help members. 

Healthcare needs arise at all times. Members don’t have time to wait hours or days to receive answers. If members are forced to wait too long, they may end up making their own decision and lose the benefits of care navigation altogether.

What does a health guide do?

Much of what makes healthcare so complicated can be solved by addressing the four key pillars of a consumer’s healthcare needs:

• Billing advocacy and resolution support.

• Benefits education and access. 

• High-quality provider search.

• Clinical guidance. 

Navigating and supporting consumers across these pillars is the key to simplifying healthcare, improving benefits utilization, and optimizing their health outcomes. Thus, most of the services a dedicated clinical guide performs fall into these four categories.

Let’s dive into each one.

• Billing advocacy and resolution support.

Unexpected bills are one of the most frustrating parts of healthcare. With nearly 80% of medical bills containing errors and roughly 65% of consumers reporting they don’t understand their medical bills, health guides can offer members a lot of value here. Anytime a member reaches out with a complicated claim, a health guide can review the bill and explain it to the member. If anything looks off, they manage the dispute with the carrier and provider, saving members time and money.

• Benefits education and access.

The benefits that employers provide continue to improve and expand, but employees don’t always know about the benefits they’re offered and how to use them. In fact, three quarters of employees spend less than one hour reviewing plan information during open enrollment, and 41% of employees spend less than 30 minutes. Further, roughly 4 out of 5 companies report that their employees don’t open or read benefits materials. Health guides can not only educate members about the benefits available to them but connect members to their benefits so they can begin using them. Whenever a member engages with a dedicated clinical guide, that clinical guide takes the opportunity to inform the member about their benefits ecosystem, encouraging adoption and optimizing benfits utilization, navigating members to and through them.

• High-quality provider search.

The quality of a provider a patient sees has a tremendous impact on the cost and outcomes of their care. But 31% of consumers don’t know how to tell whether a provider is even in-network, let alone if they’re high quality. Reviews online are often rating providers for things like wait times and office cleanliness, not the clinical outcomes of patients who see the provider. Health guides play a critical role in steering members to high-quality, in-network providers. First, health guides identify high-quality in-network providers who meet the needs of the member. Next, they connect with the provider to make sure they are in-network and accepting new patients. Finally, they make an appointment on behalf of the member at a time that’s convenient for them. By empowering members to see the highest quality providers, health guides set them on the best track to be better healthcare consumers.

• Clinical guidance.

Members often find themselves at the precipice of important healthcare decisions that can have an outsized impact on their health outcomes and costs. The reality is, unless an employee has a doctor or nurse in their family, they don’t have a clinician to turn to prior to making that care decision. A dedicated clinical guide, a health guide with a clinical license, like a nurse, works directly with the member to provide condition triage, care decision support, coordination of care, and lifestyle management. Instead of guessing what they need, members have on-demand access to licensed clinical experts who understand their needs and can guide them to the right care. 

Dedicated clinical guides, such as nurse practitioners and registered nurses, engage directly with members, answer their questions, guide them to the best care, improve benefits utilization, and support them through their care journey. 

Clinical guidance is a key component of what a health guide does and is the largest driver of benefits utilization and value of care navigation.

How do health guides drive maximum healthcare value?

Care navigation services that save employees and employers time and money are effective at improving the healthcare experience and helping employees understand and appreciate their benefits. Maximum healthcare value, however, comes from steering members to high-quality providers and delivering clinical guidance. To drive this value, care navigation must have two-way communication between the health guide and the member. Clinicians can’t just wait for members to reach out when they think they have a care need, they must use technology, data, and analytics to perform proactive outreach to members who stand to benefit most from care navigation.

To maximize the benefits of healthcare navigation, it must be delivered by expert health guides and clinicians who not only assist members when they need help, but also practice targeted, proactive outreach. High-touch care navigation solutions with health guides who work one-on-one with members simplify healthcare, transform the member experience, improve outcomes, improve benefits utilization, and bring healthcare value to employees and their employers. 

Ready to connect your members with their own health guide? Let’s talk.