Care navigation is becoming more recognized as an effective cost containment solution for employers. However, understanding the differences between vendors is important.
The term “healthcare advocate” can mean many different things. And not all definitions are equal. In this blog post, we’ll talk about what a healthcare advocate does and what makes a good one.
What is a healthcare advocate?
For some vendors, healthcare advocates are customer service representatives with no medical experience. In this model, an advocate’s primary responsibility is to help members find in-network providers. If a member calls in and needs a specialist to do shoulder surgery, the advocate will recommend in-network providers.
There’s nothing more to it.
For other vendors, healthcare advocates are medical experts with experience providing patient care within a clinical setting. This gives them “real world” knowledge to help members navigate their care and our health care system.
In this model, advocates go beyond simply referring in-network providers. They work to understand what a member needs and will advocate for the best care every step of the way.
How do they do this?
First, they start by fully assessing the member’s needs. Then, they provide recommendations on treatment options. Finally, they help the member find the highest-quality, most experienced providers.
What makes a good healthcare advocate?
A good healthcare advocate must have a thorough understanding of the health care system as well as experience and expertise in navigating it.
But that’s not all.
To be most effective, a healthcare advocate should also have extensive clinical expertise. They use this to help members better understand their illnesses or injuries, clarify treatment plans, and explain what they should expect along the way.
When a member is more informed about their situation, they’re able to make smarter decisions about their care. An advocate will also “stand-up” for a member to make sure they’re getting the care that’s right for them.
A good healthcare advocate will:
- Answer member questions about their conditions or treatment plans.
- Explain diagnoses and treatment options.
- Create goals to help members better self-manage their health, including keeping track of things like taking medications or scheduling appointments for follow-up visits with doctors and/or facilities.
- Protect members from unnecessary, wasteful treatment.
- Ensure high-value care that is clinically and financially appropriate.
Without a clinical background, it’s impossible for a healthcare advocate to adequately guide, support, and advocate for each member.
What should you look for in a healthcare advocate?
A healthcare advocate’s role goes beyond simply looking at a network and choosing a physician. As stated above, they really serve to educate members and fight for the best care.
At SentryHealth, all of our healthcare advocates are Registered Nurses. This is important because they have the medical knowledge needed to provide high-value, personalized support. They assist members through an episode of care, from finding physicians with the best outcomes, to obtaining second opinions and offering alternative options. They can’t successfully do that without clinical expertise.
Our Registered Nurse Advocates also have experience with chronic conditions, mental health, medication management, and more. Applying this knowledge and past experience, they better understand what each member is going through and can take a whole-person approach to care.
Most care navigation and medical advocacy vendors don’t utilize RNs and don’t require clinical experience. In fact, many simply require a high school diploma and some medical terminology knowledge. In these instances, they rely heavily on technology to generate solutions that are relayed to the member.
While technology is very valuable when it comes to driving informed decisions, it can’t be the endgame when it comes to personalized care. There must be a clinical expert digging into what a member needs, even if they aren’t saying it out loud. They also need to be able to interpret what is being presented and then use their clinical judgement to provide recommendations. That’s the importance of a high-tech, yet high-touch approach.
In summary, care navigation and medical advocate programs hold tremendous value for employers and employees. But it’s important to ensure they utilize clinical staff experienced in a variety of conditions, procedures, and treatments.