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Clinical guide: The MVP of care navigation.

By Paula Bush

A clinical guide is a must-have in a winning health benefits strategy. Does your benefits offering have what it takes to attract and retain top talent?

Care nav Super Bowl blog image

When my son was a child, I would spend most weeknights watching him play football at school. There was something special about the interaction between the players and parents that made us all feel like a tight-knit community. As a result of these shared memories, watching those games became one of my favorite pastimes.

On the surface, it may seem strange to draw comparisons between healthcare navigation and football. As you dive deeper though, there are more similarities than you may expect. In particular, care navigation and football both require strong offensive and defensive approaches. The observation in football, right or wrong, is that offense wins games but defense wins championships. While any football team can have a rock solid defensive strategy, without the right lineup in place to execute plays and advance the ball down the field to ultimately score touchdowns, they're not going to win any championships. One important goal of care navigation is to improve the health outcomes of members, and in order to do that, solutions must have a proven offensive strategy.

Let’s dive in deeper on what it really takes for navigation solutions to win:

Defense is not enough.

Typically, if a member has a question about their healthcare, they’d leverage their care navigation solution to reach out to their clinical guide directly. Let’s say a member was unexpectedly billed nearly triple for their recent doctor’s appointment. They would then reach out to their health guide, explain the issue, and the problem would get resolved, saving the member unnecessary out-of-pocket expenses and eventually ending the interaction. This is a common example of the defensive approach seen in care navigation that allows the member to get their problem resolved quickly, but doesn’t necessarily solve long-term health issues. 

A defense-only strategy addresses the immediate need, but latent gaps in care might fall through the cracks, leading to unmet health needs and higher costs. All of this begs the following questions: (1) what if the health guide took a more ‘offensive’ approach by diving into a member’s unmet health needs, and (2) what if health guides engaged members identified with gaps in care through proactive outreach?

Offensive strategies: The key to winning.

Football is a game of adjustments. Yes, there is strategy involved, but anything can happen on the field and coaches must be prepared. The fast-paced nature of the game of football also remains true in patient navigation. In order to be successful at improving health outcomes, there are two offensive strategies that care navigation solutions must focus on:

  1. Stacking your bench with two-way players who excel at both offense and defense. So what does this mean? In simplistic terms, you take defensive opportunities, or those moments that matter, and use them to play better offensively. For example, if a member reaches out to their health guide about a dental billing question and the health guide sees in their profile that they haven’t seen a primary care provider in over a year, their health guide will proactively nudge the member about getting a preventive exam scheduled, assess the barriers to care, and guide them to the highest quality doctor that is best for the member’s needs. Care navigation solutions pair members with a healthcare advocate who is the quarterback for all of their healthcare needs, creating a more personalized approach and trusted relationship. Every member has a different and unique care journey that is supported by a team of experts or the offensive line. By being proactive and using smarter clinical support at every interaction, the right questions are asked to best understand a member’s true health needs. 

  2. Engaging members of interest through a proactive, offensive approach. The data shows that 60% of adults in the U.S. are living with at least one chronic condition, accounting for 90% of the nation’s annual healthcare expenditures, which stresses the importance of engaging these members, many of whom might not reach out themselves. In order to run the offensive playbook correctly, you have to create a methodology that defines these members as rising- or high-risk or identifies members that have gaps in care (the individuals who most need their health guides' support). Once these members are recognized, their health guide proactively reaches out. This is an offensive strategy that says, “we know you are busy and we’ve got your back–let us do the blocking and tackling for you.” For instance, a member might be overutilizing the emergency room to manage their asthma, prompting their clinical guide to call the member directly to help navigate and support them in getting the necessary care to better manage their condition, leading to improved health outcomes.

Inside Rightway’s offensive playbook.

In football, before the offensive team comes out onto the field, they must understand the plays they are going to run. With care navigation, clinical guides must understand which members need the most support before they can run plays and proactively reach out to them.

Rightway’s care navigation solution has a proprietary risk scoring methodology (our offensive playbook) that incorporates multiple data sources to classify members as either ‘rising risk’ or ‘high-risk’. Medical and pharmacy claims give us the ability to analyze each member’s longitudinal medical history and identify medical conditions that are either active or deteriorating. We also have user surveys that provide insight into self-reported conditions that are not referenced in claims data, as well as behavioral and lifestyle information (e.g., nutrition and exercise habits). Lastly, our team analyzes employee chat encounters in the event that a member has disclosed to a clinical guide that they have a chronic or acute condition. Using a proactive clinical assessment model allows for better guidance and support in a member’s care journey. 

Once rising- and high-risk members have been identified, our health guides proactively conduct outreach and send out personalized messages, notecards, and mailers in order to stay connected to our members. Having a clinical guide as a member’s quarterback allows them to catch health problems early, uncover gaps in care, and identify preventive screenings that have been missed. All of this is done to improve overall health for members and ultimately “win” games.

Good teams win championships.

For too long, the prevailing notion in football is that defense is the key to winning championships, and we firmly believe that while important, it is not entirely true for care navigation. Having a superior offense in care navigation makes your chances of winning even greater. Given what we know about the healthcare ecosystem, it seems that good teams who have both, actually win championships. Adopting an offensive approach to navigation is the only way to unlock better care, happier people, and lower costs. Nothing is more important than improving the health and wellness of members, and a combination of defense and offense will prove to be the only way to win the care navigation Super Bowl.

Read more about how Rightway’s smart clinical navigation can deliver better care, happier people, and lower costs. If you're ready to win the care navigation Super Bowl, talk to us today.

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