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December 5, 2018/Nursing/Quality

Navigating Patients Through a Complex Care System

Helping patients stay in network and get the care they need

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Cleveland Clinic is at the forefront of creating a model of care that optimizes the patient experience by connecting patients to the right care, in the right place, at the right time.

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Cleveland Clinic’s Quality Alliance Network Navigation Team was assembled in January 2018 to advocate for patients in an increasingly complex healthcare system. Navigation team members use relationships with primary care providers, home care nurses, and case managers at the payer level to connect patients with the services they need within the insurance network.

“It’s a very new way to partner with insurance companies,” says Program Manager Margaret M. Cole, MSN, RN, CCM, who leads a team of three lay navigators and three RN navigators. This is a shift to a value-based care model that aims to optimize patients’ status and improve their quality of life. When patients are satisfied with the care they receive, they may be more likely to proactively stay within our system.

The concept was born out of a narrow network business growth strategy to design onboarding and navigation for Medicare and commercial patients new to Cleveland Clinic and/or cobranded insurance plans.

Mitigating risk

“We help patients get where they need to be,” Cole says. “We help mitigate risk by making sure patients are registered correctly and are receiving care within their network vs. care outside of the network.”

The care model, Cole says, links patients to in-network primary care providers to identify needs, interventions and services.

Cole calls the model patient-centric. Navigation team members help connect patients with physicians and services in their insurance network, facilitating appointments if necessary. The navigation team also serves as a liaison to insurance providers and nursing care providers. With information from the payers, the navigation team can work with nursing care providers to optimize a patient’s benefits.

The team serves about 2,000 members in Cleveland Clinic’s Medicare narrow networks (which limit choices of doctors and hospitals) and also patients in the commercial narrow networks – a population in which some are unmanaged patients who are not connected or aligned with a Cleveland Clinic primary care provider. The service is now expanding in more at-risk contracts.

A new frontier

Cole says the program is new and undefined, challenging navigators to use their highest level of judgment, be innovative and put their experience to work building relationships across different care venues.

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