Home Care Provider Devoted Guardians Slashes Costs, Readmissions With Banner Health Program

Home care provider Devoted Guardians has implemented a patient care navigation program in collaboration with health system Banner Health.

This initiative is led by a social worker who focuses on clients’ social determinants of health (SDOH). The program has successfully engaged 500 unique clients, resulting in more than 3,000 touchpoints and nearly 300 referrals. As a result, there has been a 49% reduction in hospitalizations and estimated savings of more than $5 million.

The program employs a multi-specialty approach, incorporating certified navigators and nurse navigators to assess and address clients’ clinical and social needs. Key services include risk stratification, ordering durable medical equipment, providing home therapy and delivering mobile pharmacy services.

When clients first seek services from Devoted Guardians, an initial navigation assessment evaluates their clinical and social needs. This assessment develops a risk stratification to identify potential risks related to the client’s current condition.

“The goal is to bring trained professionals, along with provided caregivers, into the home to focus on the client’s needs in detail and coordinate everything within their continuum of care,” Devoted Guardians COO Justin Tyler told Home Health Care News. “Our navigation team actively engages with the client’s primary care and specialty providers, making referrals to specialists. We aim to involve their holistic care team, providers, and family or we make necessary referrals.”

Tyler emphasized that his team strives to understand what motivates clients to engage in their own care and promotes accountability at home, ultimately helping them become more independent.

For the past three years, Banner Health has supported the care navigation program by providing grants through its Banner–University Family Care/Arizona Health Care Cost Containment System (AHCCCS) Complete Care plan. This plan serves participants in Arizona’s Medicaid program, AHCCCS. AHCCCS Complete Care is an integrated health care plan that combines physical and behavioral health services to improve care coordination among providers and enhance health outcomes for its members.

These grants are awarded based on proposals that emphasize innovative ideas not typically addressed by standard health care systems, according to Devoted Guardians CEO Aaron Sinykin. Importantly, eligibility for the program does not require individuals to be patients of Banner Health. It is open to everyone in the community, including private pay clients.

“Our population includes the elderly and physically disabled, which automatically qualifies them for navigation,” Tyler said. “Everyone who comes through our doors receives at least one point of contact at admission when they first begin receiving services. After that, additional contact depends on individual needs.”

Tyler mentioned that specific criteria will prompt the team to deploy navigation services.

“For instance, if someone who has not engaged with navigation for the past six months experiences a health issue and is hospitalized, that would trigger immediate engagement from our navigation team,” he explained. “We use communication tools with our caregivers, client care managers and schedulers, and anytime there is a note regarding a change in a client’s condition, that serves as a trigger for deploying navigation.”

Furthermore, this program extends its support beyond just those within the Devoted Guardians’ care system. It also assists individuals who have not yet been referred to their services.

“About once a month, we engage with someone who is not a Devoted Guardians referral or client, but they come to us through an SDoH portal. We help them get on the right track,” Tyler said. “We provide information that may be publicly available, but they may not know where to find it, or we help guide them through the process of applying for Medicaid or disability benefits. This allows us to reach some non-clients as well.”

Navigation programs were among the first initiatives to embrace value-based care by introducing nontraditional services into the medical space. Specialty medicine groups have incorporated non-physician services to guide patients through SDOH considerations and the care continuum, ultimately reducing medical costs.

“We aim to expand this concept into a new area of service that we believe has not been sufficiently discussed or addressed at this level,” Synikin said. “Currently, we are working to demonstrate that engaging beyond just the caregiver can create a more significant impact on the client. As a result, they become better engaged with their health. We have historical data showing a reduction in the number of times our clients were hospitalized during the past year, as well as a decrease in readmissions during the last three years, which allows us to estimate the average savings for health plans or the overall health care system.”

In 2021, the company reported 343 hospitalizations. By 2024, this number had decreased to 219, despite the company’s more than 70% growth during that period. Due to their efforts, approximately 121 hospitalizations were avoided in 2024, resulting in insurance savings of $2.1 million, according to Sinykin.

“Until recently, people did not recognize our role within the health care system,” Sinykin said. “Now, there is a greater understanding that we have substantial opportunities to influence the health outcomes of our clients. By incorporating ancillary and wraparound services, we can enhance our offerings and integrate necessary medical services. This makes our program a powerful one that is genuinely helping people. Our mission is to promote positive health outcomes and provide peace of mind and comfort to families.”

Sinykin expressed his desire to expand the program across Arizona and throughout the country by using Devoted Guardians’ sister brands and exploring different service lines.

“I see this as just the beginning of our journey. We hope that by continuing to highlight our efforts, we can attract more visibility and investment into this field,” he said.

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