Population health 6 minute read

CommonSpirit Health Closes Care Gaps

Discover how CommonSpirit Health closes care gaps with personalized, community-based care navigation in partnership with Docent Health.

CommonSpirit Health Closes Care Gaps with Personalized, Community-Based Care Navigation in Partnership with Docent Health.

CommonSpirit Health, a nonprofit health system serving patients in 137 hospitals and 1000+ care sites across 21 states, and Docent Health are expanding their virtual care navigator program to build on the program’s success in improving health outcomes for maternity and orthopedic patients. Docent Health is a leader in consumer engagement and patient navigation technology and services. Partners since 2016, the virtual care navigtion program has paired patients with care navigators who are in and of CommonSpirit’s communities and provide individualized guidance to patients.

The Centers for Medicare and Medicaid Services (CMS) has stated that achieving health equity and driving improvements for all patients requires further investment in tools that address social determinants and close care gaps. CMS notes that social determinants of health – including housing, transportation, education, social isolation, and more – affect minorities in particular, and negatively impact access to care and health outcomes. However, even with the recent attention on racial injustice and the correlation to poor health, CMS finds efforts to lessen these inequities often reach a fraction of the population, perhaps as few as two percent of all patients. Both payers and providers cite outdated tools, resource complexity, and bandwidth constraints as factors limiting their ability to elevate support for social determinants.

Docent Health’s engagement model captures and aligns numerous unique patient attributes and maps CommonSpirit’s resources to those of local, community-based organizations. The program will expand not only geographically to include more of CommonSpirit’s care sites across the country, but the virtual care navigators will also improve continuity of care among the health system’s hospitals and extend to primary care practices, behavioral health specialists, and community-based organizations.

“We simply cannot place enough value on the improvements we’ve seen in our patients’ health as a result of the individualized, community-based navigator partners who augment the work of our clinical teams,” said Alisahah Cole, MD, system vice president of population health innovation and policy at CommonSpirit Health. “The real-time capabilities from Docent Health’s platform take away much of the burden of care coordination, allowing us to scale services, which is particularly important for vulnerable or underserved patients in CommonSpirit’s communities. We are excited to bring Docent Health’s human-centric model to more of our patients with complex care needs.”

Using artificial intelligence to analyze care data, Docent Health’s platform can quickly coordinate personalized care by predicting and generating the right referrals into CommonSpirit’s workflows. Together, the technology and care navigator partners individualize support and proactively guide patients to local resources, educational programs, and care preparation. The multi-language cloud-based navigation platform interprets unique patient attributes in real-time to streamline interactions with the patient such as reminders, phone calls or text notifications, resource recommendations, and surveys, in addition to sending tasks out to care navigators and clinical care teams.

CommonSpirit and Docent Health are expanding their partnership based in part on the results of a multi-year study that quantified how Docent Health’s innovative technology and human care navigator program has successfully improved patient outcomes. The model also lowered the cost of care across all patient types, including among vulnerable populations and specifically for Medicaid patients. The study included more than 10,000 of CommonSpirit’s patients and found:

Maternity Patients:

New mothers had a 10 percent shorter average length of stay (2.29 vs. 2.46 days)

Medicaid neonates with complications had a 1.8-day shorter length of stay (4.3 vs. 6.13 days)

There was a 37 percent reduction in pre-term births for mothers on Medicaid (7.5 percent vs. 11.9 percent)

Orthopedic Patients:

Orthopedic patients had a 45 percent shorter average length of stay (1.93 vs. 3.5 days)

30-day readmission rates for orthopedic patients were 71 percent lower (1 percent vs. 3.5 percent)

“As an industry, we’ve known that community-based culturally responsive programs work but we’ve lacked the technology to deliver them cost-effectively, at scale. Our tech-enabled approach is driving better outcomes for physicians and helping to build trust and engagement, and improve health in the communities that need the support the most,” said Royal Tuthill, co-founder and president of Docent Health. “We are honored to continue our work with CommonSpirit to address health inequities in more of their communties, which is especially needed during this challenging time.”

The virtual care navigator model has led to more comprehensive support for patients with complex health care needs, and ensures a greater degree of care continuity. An internal reseach study analyzed data related to 10,220 of CommonSpirit’s patients between the years 2016 and 2018. Over sixty percent of patients in the research study were either Medicaid or Medicare patients, and were from a mix of urban, suburban, and rural communities. CommonSpirit’s study controlled for numerous variables, including age, race and ethnicity, and physician.

The collaboration is expected to extend Docent Health’s care navigation technology and services across 11 states and more than 60 of CommonSpirit’s care sites.

About CommonSpirit Health

CommonSpirit Health is a nonprofit, Catholic health system dedicated to advancing health for all people. It was created in February 2019 through the alignment of Catholic Health Initiatives and Dignity Health. With its national office in Chicago and a team of approximately 125,000 employees and 25,000 physicians and advanced practice clinicians, CommonSpirit Health operates 137 hospitals and more than 1000 care sites across 21 states. In FY 2020, Catholic Health Initiatives and Dignity Health had combined revenues of nearly $29.6 billion and provided $4.6 billion in charity care, community benefit, and unreimbursed government programs. Learn more at

About Docent Health

Docent Health is a venture-backed healthcare experience technology and services company focused on helping healthcare organizations transform and truly embrace a consumer-centric approach to healthcare. The company’s mission-driven platform and services combine digital and human interactions to guide customers on journeys tailored to their specific needs and preferences. By utilizing Docent Health’s platform, health systems and payors can provide personalized, empathetic experiences at scale and support a multitude of complex care pathways. For more information, visit or follow us on Twitter and LinkedIn