Navigating today’s healthcare landscape can be tough, especially for high-risk Medicare and Medicaid patients who have to go it alone.

From seeing primary care providers and specialists, to coordinating appointments at rehab and out-patient facilities, to understanding the services available under commercial and government health plans, coordinating one’s own healthcare can be daunting without an understanding of how the healthcare system works. And more often than not, it leads to gaps in care navigation.

It doesn’t have to, though – particularly as more health organizations transition to value-based care.

In fact, a well-designed care coordination strategy that relies on care coordinators to close gaps in navigation lowers costs, optimizes care and improves patient outcomes. Care coordinators, working on behalf of primary care providers, can advocate for patients – particularly the most vulnerable ones – by communicating with all parties involved in mental health and physical health, as well as social or economic well-being.

And it’s a win-win situation for doctors and patients alike.

Patients win by having care coordinators support them throughout their healthcare journey.  Armed with an understanding of how to navigate the healthcare system and educate patients, coordinators optimize care and improve patient outcomes.

How?

By removing barriers, both inside and outside the healthcare system.

For example, I arrange Medicare-covered transportation to medical appointments and calls with Medicare to ensure patients understand their coverage. I’ve coordinated calls with rental agencies to help patients with their housing situations, and set up calls with state agencies to help patients file for Medicaid and other supplemental insurance. I talk with patients to make sure they understand their conditions, diet plans and exercise programs, and how to take medications.

In essence, I’m looking to alleviate patient stressors while factoring in any social determinants of health. And sometimes, all I do is listen and provide a little bit of support.

Not long ago I was in contact with a patient with hypertension. Her blood pressure readings were very high at her most recent doctor visits, so I wanted to make sure she was monitoring her condition and taking her meds. She said she was doing both, but was angry, not sleeping, and stressed-out over a custodial issue regarding her grandchild that she had not previously discussed with her doctor.

I told her that she could be more helpful to her grandchild if she was in good health. She agreed, and followed up with her doctor about adjusting her medication.

Care coordinators also explain to patients what’s going on behind the scenes on their behalf. This often gives patients a sense of empowerment that opens doors to more effective communication.

As for primary care providers, they win by having an extra layer of communication with patients to ensure the right care (and for the right reason, and in the right setting) is provided. Further, practices participating in the Medicare Shared Savings Program are incentivized to utilize care coordinators in order to promote annual well care and reduce non-emergent emergency room visits and unnecessary admissions. All of which boost CMS quality-measure reporting and performance bonuses.

Addressing navigation gaps is leading to better care, and as a result, patients and doctors alike are winning.