New strategies to improve the patient experience

How clinically integrated networks and care navigation programs work together making healthcare easier to navigate

March 16, 2021

Randy Coughlan, MBA | Director of Population Health

"Difficult, confusing, and frustrating," are words used to commonly describe a personal experience interacting with the U.S. healthcare system. These are some of the many adjectives used that are suitable for print. In fact, only 12% of U.S. adults have the health literacy skills needed to manage the demands of our current, complex healthcare system. And even this segment of the population can experience compromised abilities to absorb and use health information due to stress or illness.¹ Some doctors struggle to make sense of the system outside the confines of their office. Simply stated, healthcare is incredibly complex. 

Care navigation benefits the member and employers

Most of us have spent countless hours trying to translate and understand our healthcare product and system, even before the first visit to a doctor. Reading through insurance plan documents, deciphering service coverage, understanding deductibles, and transferring medical records are all activities that take an extraordinary amount of time and add undue stress to our lives. 

The good news is that there is increasing recognition that members need and want help navigating the healthcare system – the approach is aptly referred to as care navigation. While this broadly used term overlaps with member engagement, care navigation typically combines user-friendly technology with clinically trained staff. The clinically trained members are often called care navigators or member advocates. This team efficiently assists members in finding the right doctor, figuring out a procedure cost, or preparing a list of questions they should ask the doctor at their next visit. 

One of the main advantages of this approach is having a central point of contact that is specifically designed to make healthcare decisions easier for the member... a crazy idea, right? This means supporting multiple communication channels based on member preference: chat, text, email, and of course, the good old-fashioned telephone. These solutions typically include an online self-service portal empowering members to find information easily and quickly. For those who would prefer to talk things through with a real person or don’t know where to start, a care navigator is just a click or call away.

Inherent to this approach is a shift in mindset - it is not all on the member to schedule, manage, and maintain their care. The care navigation approach has multiple benefits for both the member and employer. Members can lean on care navigators to do research, provide options, and guide next steps saving valuable time, energy, and stress. With 88% of the population not having the necessary health literacy skills, why are members expected to make important healthcare decisions for themselves and their families without any support? The obvious answer is we can't, and we shouldn't. A care navigation program's job is to help relieve the enormous and daunting task of managing care for oneself or a family member. Without this help, it can be a full-time job.

For example, when a patient receives a bill from a provider and suspects it was sent in error, the member often doesn't know who to call – the insurance company or the provider? With care navigators, the member can call (or message) and ask for the care navigation team to review on their behalf. If there is an error, the care navigator can walk the patient through the necessary steps to resolve it. Care navigation programs employ experts who review bills all the time and know the most efficient way to find a resolution making them natural advocates for the member. Along with advocacy, care navigators provide education and continued support with many issues including billing details and questions. 

Having more informed and engaged employees, employers benefit in a variety of ways. With the recent proliferation of care navigation solutions in the large employer market, signs indicate that members value having a more accessible and painless way to sift through healthcare complexity. Also, if done right, care navigation can help bend the cost curve by directing members to the appropriate acuity of care or helping to find alternatives for procedures or medications that are more cost-effective. A study conducted Rightway, Embright’s member experience partner, reduced the total healthcare spend for Braman, a national auto dealer with 4,500 employees, by 5% and non-catastrophic spend by 9% in year one producing a 4X ROI. Additionally, employee engagement with this new approach reached 62%

Healthier employees equal happier employees leading to increased productivity and more engagement. Employees can actually do their job and do it well when they are not stressing about healthcare questions and concerns.  

Care navigation within clinically integrated networks 

So, how do care navigation programs work within clinically integrated networks (CINs)? As CINs focus on cost-containment, the experience of care, and care coordination, CINs can certainly benefit from the deployment of care navigation solutions. In many ways, a care navigation approach is compatible with the objectives of a CIN and can be seen as one of the key tools at its disposal to support the achievement of its goals.

Since CINs are relatively new entities and most members do not fully understand what it means to get healthcare delivered within a CIN, care navigators can play a key role in CIN member education. Care navigators provide needed education in what a CIN is and all it has to offer, such as connecting members with the right providers and other resources that are best suited to their needs. 

Data integration offers another opportunity for CINs to effectively leverage the capabilities of care navigation solutions. A fundamental objective of CINs is to aggregate and share clinical information across the network so it can be used to improve care coordination and outcomes. Combining comprehensive, up-to-date patient information with care navigation solutions allows for more meaningful interactions. For example, a member reaches out to a care navigator via text message about a coverage question. The care navigator quickly provides the member with the information requested and informs the member that they are overdue for a cancer screening. Then offers to schedule an appointment on the member's behalf. How convenient! This can be achieved through clinical integration. 

These types of interactions make life a little bit easier for the member, improve the healthcare experience overall, and when achieved across an entire population can lead to meaningful improvements in quality and outcomes. With CINs and care navigation solutions both relatively new entrants to healthcare, it's promising that these complementary programs can develop integrated offerings empowering members and employers to make the best healthcare decisions for themselves, families, and the whole population.  

1 AHRQ Health Literacy Universal Precautions Toolkit. Agency for Healthcare Research and Quality (AHRQ).

2 Case Study: National Auto Dealership - 2018.