Rely Health Value Based Care PCP Navigation Hub

Goal

Establish a dedicated navigation team focused on maximizing patient value by addressing care gaps early and providing ongoing operational support.

Overview

Primary Care Practices are responsible for managing thousands of lives across vast geographical regions. The Rely Health Navigation Hub is designed to streamline patient experience and communications to ensure that every patient in your practice receives personalized interactions to guide their optimal care journey. We will design your Navigation Hub specifically to meet your patient population and workflow needs and deploy a team of empathetic patient care navigators, who utilize a customized instance of the Rely Health technology suite, to meet your population's needs.

Services: Navigation Hub

A team of patient care navigators will ensure that all patients receive high-quality care through a proactive approach. This approach drives lifetime value by fostering strong patient relationships and enhancing overall patient satisfaction.

1. Quality Care Caps: Navigators will leverage EHR data and Rely Health technology to identify real-time quality care gaps (e.g., Well Care Visits – Ages 12 - 17, Colorectal Cancer Screening) and assist your practices providers in closing those gaps. They will act as a back office support team, in conjunction with the patient’s PCP and existing care management resources, to ensure gap closure.
2. Operational Extension: Navigators will streamline the operations of existing workflows, particularly those related to intake and patient surveys or questionnaires. This ensures that we remove administrative burden from any tasks that do not enable clinical staff to perform at the top of their license.
3. Follow-Up Actions: For existing workflows like Social Determinants of Health (SDoH) & Obesity Screening, navigators will act as a “last mile” care coordination and delivery solution. They will prompt workflow closure and ensure that the next best actions are scheduled and coordinated with the patient.
4. Ongoing Longitudinal Care: Navigators will provide continuous support to ensure patients receive high-quality care throughout their healthcare journey. Tailored to each patient's needs based on their PCP's clinical notes, unique pathways will be designed—such as Chronic Care, Community Placement, and Annual Wellness. Pathways segment the population into the most appropriate “next best step” categories, guiding care proactively reducing the total cost of care.

With Rely’s Navigation Hub, we will fast-track patient activation through intelligent audience generation and automated outreach, driving patient volume and advancing the quadruple aim. This proactive model of continuous engagement will not only activate patient outreach and reduce total costs of care, but also improve patient satisfaction and outcomes.

Summary

The Navigation Hub for Primary Care Practices aims to elevate patient experience and provide comprehensive support for your patients, all while reducing the administrative (documentation/outreach) burden on your team.

By implementing a dedicated team of patient care navigators, this initiative strives to close quality care gaps, deliver exceptional patient care, enhance satisfaction, and drive lifetime value across your entire practice.

Contact Rely Health to optimize your Care Navigation.