Those who work inside the increasingly complex maze that is the American healthcare system can find it challenging to navigate. For those on the outside, the maze can be simply overwhelming.

No wonder so many patients either slip through the cracks or fail to follow through with the care they need. And no wonder more and more organizations are turning to navigators to help guide patients through the maze and make sure they get the care they need.

Hidden costs

Healthcare is transitioning to increasingly complex value-based criteria, and providers may be tempted to lean on clinical staff to help with patient navigation; but doing so forces staff to practice below their skill and education levels and may come at the cost of compromising both patient satisfaction and overall quality of care.

Navigators — non-clinical personnel trained to guide patients through the fragmented and confusing healthcare landscape — are one obvious solution. “Although many discussions of the healthcare workforce focus on doctors and other occupations requiring advanced degrees, the healthcare system would not function without pre-baccalaureate workers — those with less than a bachelor’s degree,” notes the Brookings Institute in a 2014 report.

Using navigators, says the report, can help “achieve the ‘triple aim’ of improving the experience of care, improving health outcomes, and reducing per capita costs.”

Or as Eileen Fuentes, a navigator at  New York Presbyterian-Columbia, describes her job, it’s about translating “doctor talk” into a language that all patients understand, as well as helping them handle all the logistics involved in procuring appropriate care.

Documented impact

A 2017 study published in JAMA Oncology underscored the positive impact that navigators can have, noting that navigated patients incurred significantly lower costs, had fewer emergency department visits, fewer hospitalizations, and fewer intensive care unit admissions than non-navigated patients. “Lay navigation programs should be expanded,” the study argued, “as health systems transition to value-based health care.”

Navigators are also seen as an important tool to address language and cultural barriers that can perpetuate high rates of disease and reduced access to care among low-income Americans, racial and ethnic minorities, and other underserved populations.

“Patient navigators can break through literacy barriers, build trust, reduce fear, and support the improvement of patient-provider communication,” the same study found.

Lucrative opportunity

Navigators not only help plug the gaps that result in suboptimal care, they can also help providers reach the millions of current and future Medicare patients who have multiple chronic conditions and who’ll either now or later qualify for CMS’s Chronic Care Management Program — an under-publicized win-win of a program that helps seniors get the care they need, while offering the potential for significant financial rewards to providers.

Under the program, caregivers who provide non-face-to-face monthly consultations with these patients can bill CMS for their services — and in doing so, earn some of the hundreds of millions, or even billions, of federally funded dollars CMS says have been set aside for the program.