Care Continuity is a patient navigation and care logistics management company that leverages analytics, workflow automation, and expert care coordinators, to partner with hospital care management teams. We deliver seamless patient transitions and access to care across all key access points.

Our tech-enabled patient navigation solution is used by top health systems and payers to support patient care journeys and help healthcare providers deliver timely follow-up care to reduce gaps in care, prevent hospital readmissions, reduce Emergency Department returns, and limit patient attrition.

HOW IT WORKS

Network Activation

The first phase of a Care Continuity engagement begins with network activation, creating a real-time interface between the core hospital Electronic Management Record (EMR) system and the Care Continuity platform. An admission-discharge-transfer (ADT) feed and a clinical documentation interface are established for risk scoring, enabling patient care navigators to screes patients most in need of support, while also populating the workflows based on clinical recommendations.

Network activation also includes engaging ambulatory providers (both employed and independent) to build out the Care Continuity platform with scheduling preferences, insurance acceptance, patient panels, ambulatory care management programs, and more.

Care Concierge engagement

Behind Care Continuity’s finalized workflow are trained care coordinators, which we called Concierges. The Concierges engage patients at bedside as part of the discharge process to increase post-discharge plan adherence.

Enhanced patient profile

As Concierges engage patients during the discharge process, they work to confirm the patient’s primary care physician (PCP) or assign a PCP, if necessary. They also assess potential barriers to accessing care post discharge, including identifying any social determinants of health (SDOH) issues and building out the patient’s care team with family members, when appropriate.

Discharge instructions

All follow-up care scheduled by a Concierge is at the direction of hospital clinicians and in coordination with ambulatory providers and case management. In an inpatient scenario, Care Concierges are typically included in daily inpatient huddles with the Inpatient Case Management team, ensuring all scheduled care is arranged prior to the patient being discharged home. Patients discharged to a post-acute facility are monitored during their stay to ensure follow-up care is scheduled on an appropriate timeline.

Patient Care Plan Adherence

The Care Continuity Concierge team is responsible for monitoring patient care plan adherence post discharge, including ensuring patients attend all scheduled provider appointments and physical therapy, as well as verifying medications are picked up and/or delivered. Additionally, patients receive weekly check-ins to monitor medication adherence and other post-discharge instructions.

PROGRAM RESULTS

Navigated patient = improved outcomes

Care Continuity’s program delivers results for:

• Improved high-risk care management
• Increased network utilization
• Reduced readmissions and length of stay (LOS)
• Improved patient engagement, satisfaction, and clinical outcomes
• Reduced cost of care
• Improved utilization of ambulatory care management programs

A typical engagement delivers on average:

• 30% improvement in net present value (NPV)
• 40% reduction in average time to follow-up appointment
• 87% success rate when connecting unattached patients to network-aligned physicians
• 21% reduction in re-admissions
• 35% reduction in 0-to-7-day ED return visits
• 71% of IP follow-ups within 7 days (compared to national average of 42%)

These improvements result in significant quality and patient loyalty gains, with a greater than 4:1 return on investment, self-funding the engagement.

Just as important, Care Continuity’s intelligent platform provides powerful insights healthcare organizations can rely on to improve everything from provider relationships to broader longitudinal patient support.

HOW TO ENGAGE

Care Continuity offers a “Care Navigation and Network Intelligence Evaluation” based on your organizational data and inputs to develop a detailed opportunity analysis. We’ll present our findings and offer recommendations. Whether you are in a highly competitive market and/or focused on improving performance in risk-based contracts, we can help you design a program that fits your needs. Ready for a discussion? Visit our website here to schedule a meeting today.