Health systems have a glaring navigation problem, and it’s leading to network leakage and specialist capacity challenges.
Provider organizations have poured significant resources into building expansive medical groups and aligning with specialist physician practices. Despite all this investment, prioritizing the right patients and navigating them through these networks feels a bit like herding cats.
- The referral process is fragmented and patients are often on their own to navigate
- Patients who SHOULD be high priority run into scheduling delays and fail to close the loop on specialist follow-up care
- Lost referrals impact downstream procedures and everyone – from CFOs to specialist physicians – ends up frustrated
- Health systems struggle to track the referral value chain and lack insights to identify bottlenecks and opportunities for improvement
In competitive markets, this leaky bucket problem means patients often slip through the (sizable) cracks, losing out on the care they need and taking those potential services elsewhere.
Every time a patient leaves the network, a health system loses thousands in potential downstream service line revenue. Consider the Emergency Department: In a typical ED almost 50% of patients exit before even being seen – and then another 50% fail to follow-up on their referral to a specialist. The missed opportunity for downstream services and service line growth is staring you in the face. Painful, right?
Adding to this problem, not only are patients leaving, but the right patients aren’t getting prioritized, either. Service line leaders in specialties like orthopedics, cardiovascular, and gastroenterology are managing limited appointment capacity on a day to day basis. Everyone gets frustrated by seeing lower acuity patients not in the right place when patients with more pressing, higher acuity needs are made to wait for months.
This patient leakage and low-value dynamic is happening at health systems nationwide, daily. It’s time to fix the broken state of patient access and referral management by introducing a connective tissue solution bringing together all the stakeholders within the enterprise. A solution like Care Continuity identifies high-value patients, helps all stakeholders understand their network, patient access, and referral management strategy, and drives significant customer loyalty and long-term value to their health system partners.
Let’s dive into how.
A Broken Navigation Experience
Let’s define what “high-value” means before we go any further.
A high-value patient isn’t someone who’s extra nice to nurses or tips generously, or has a money printing machine wedged under his hospital gown. Rather, these patients have urgent medical conditions or higher acuity needs and need faster specialist attention. These patients are, objectively, higher priority. And they represent a valuable opportunity, not just because they need more immediate care, but also because they drive higher downstream revenues for hospitals and health systems. Losing even a single high-value patient due to poor navigation and follow-up isn’t just bad medicine – it’s bad business.
Yet, healthcare continues to struggle with this basic logistical puzzle. The ED, often the busiest gateway into the health system, leaks like an old faucet. Nearly half the patients discharged from the ED disappear before seeing a specialist.
That’s not just a clinical concern; it’s a strategic nightmare. Every one of these lost referrals is a missed chance at substantial revenue and improved patient outcomes. Backlogs, wait times, no-shows, ED returns, and scheduling snafus plague the current broken processes across all specialties and clinical service lines.
Where Value Leakage Happens (Spoiler Alert: Everywhere)
Value leakage isn’t just an ED issue. Routine referrals from primary care to specialists suffer from outdated processes like “first-in, first-out” (FIFO) scheduling, where factors such as referral timing – not clinical priority – drive appointment matching. Patient access centers, or call centers, are concerned with efficient output of serviced calls rather than coordinating with specialist practices to align the right patients with limited appointment capacity.
This dynamic is akin to letting someone with a stubbed toe get scheduled in front of a patient with chest pain just because they showed up first.
To make matters worse, hospitals often deploy self-scheduling tools hoping to empower patients, but these tools tend to backfire spectacularly, leading to less urgent patients filling valuable appointment slots, and no-show rates that reach upwards of 30% in some specialties.
Additionally, many referrals get lost in translation. ED physicians, overloaded with work, frequently jot down specialist referrals as casual notes rather than formal orders. Patients leave without clear instructions and end up wandering over to competitors or coming back to the ED, creating a costly cycle. And specialty practices, overwhelmed by calls and scheduling logistics, fail to efficiently handle these hidden referrals, leaving both patients and revenue stranded.
Siloed Stakeholders: Why Everyone is Responsible but No One is Accountable
The referral value chain in health systems is not just logistical. It’s structural. Navigation is a bit like a group project gone wrong: Everyone has a role, but nobody owns the outcome.
Frontline physicians write referrals, patient access centers schedule appointments, service line directors manage clinical capacity, and executives track revenues. Unfortunately, each operates within their silo, rarely communicating effectively or aligning their goals. For instance:
- The CFO is responsible for ROI calculations, strategic growth, and financial outcomes.
- The CSO is looking at network leakage and trying to get a handle on his or her 10,000 foot view of the entire organization, tracking referral patterns, competition, and network performance.
- Medical group leadership is focused on quality of care, which includes dynamics like wait times, appointment capacity, and no-shows, and is a separate entity from the hospital C-suite.
- Service line leadership is focused on growth strategy in conjunction with capacity management. Service lines like orthopedics, cardiovascular, and general surgery are heavily prioritized given their outsized contribution margin to the enterprise.
- The patient access team is usually centralized and engages patients for scheduling, authorization, and general navigation but has no ownership or perceived responsibility for downstream outcomes.
- Finally, the frontline staff, clinical teams, and ED physicians are working hard and feel disconnected once the patient goes home.
Without comprehensive buy-in, navigation improvements are doomed to incremental, short-lived fixes rather than transformative change. It’s a system-wide, enterprise-level issue, and shared responsibility is why this critical function breaks down. Until now.
How to Spearhead Smarter Referral Navigation
With health systems facing limited specialist capacity, these broken referral and navigation processes need to be fixed with a smarter approach to prioritizing patients – and each fix can have a compounding effect. When stakeholders create a system where high-value patients are identified, navigated, and scheduled with in-network specialists, not only are patients more satisfied and better taken care of, but the effect on downstream utilization for key service lines is significant, too.
But how do you implement an effective program? It requires significant leg work in sophisticated data analytics and a team equipped with smart workflow technology to be able to identify the right patients. The specific capabilities your enterprise needs includes the following:
- Leverage natural language processing (NLP) to sift through clinical notes and identify any potential missing next steps or referrals (especially in the ED).
- Prioritize high-acuity or high-value patient referrals, segmenting and flagging these individuals for faster/optimal follow-up. Use machine learning (ML) and predictive analytics from past visits, as well as patient demographic and comorbidity information, no-show rates, and more to inform the decision as to whether or not a patient would benefit from additional navigation services.
- Set a culture of communication within your organization to focus on these high-value, high-needs patients, and meet them where they are (text messaging, multiple follow-ups, priority appointment slots, etc).
- Track the metrics that are important to your organization (referral metrics) and have greater clarity around how your network is actually performing. Downstream conversion rates, appointment wait times, and network leakage activity are all vital to maximizing outcomes with limited service line and referral resources.
If you want to partner with a firm that has already been around the block in this arena, Care Continuity is one example of a smarter, AI-enabled referral navigation platform tackling this big hairy problem at health systems.
Instead of leaving navigation up to chance or outdated methods, Care Continuity prioritizes high-value patients intelligently. Using sophisticated predictive analytics, their team and software uncover hidden referrals within clinical notes – at about four times the rate of traditional, faulty approaches. This drastic improvement ensures high-risk patients aren’t left hanging, reducing leakage.
By generating detailed patient priority scores, Care Continuity identifies who needs immediate attention based on clinical urgency, prior behaviors like no-shows, and potential downstream healthcare utilization. Think of it as having a crystal ball, but instead of magic, it’s driven by data and leveraging AI in a way that is immediately impactful to a health system.
Care Continuity is more than technology, though. Their team and platform acts as the connective tissue that aligns all those disparate, siloed stakeholders. Patient access centers, frontline providers, specialists, and executives suddenly speak the same language. By providing comprehensive visibility into patient navigation and referral metrics, Care Continuity fosters a collaborative environment. Everyone knows what the next best action is to take and everyone can see performance metrics like referral capture rates, appointment completion times, and no-show statistics. Fixing a system-wide challenge also requires external data to understand specialist referral patterns outside of the network, and Care Continuity brings a strategic view to put this logistics challenge front and center as a strategic priority for health systems in competitive markets.
Real-Life Results: Case Studies in Action
Let’s look at some proof. A large multi-state health system, dealing with intense competition and significant ED referral leakage, deployed Care Continuity across 20+ EDs and 5+ markets.
By zeroing in on high-value cardiovascular referrals from EDs, they boosted their in-network targeted ED referral completion rates to 85%, resulting in a 15% increase in contribution margin per case. The annualized margin increase resulted in an incremental $12.5 million for referrals from the ED.
Another regional health system with over 900 employed physicians faced similar headaches, struggling to integrate new practices and manage tens of thousands of backlogged referrals. Care Continuity introduced a referral scoring model, allowing navigation teams to prioritize effectively. The results: An 85% in-network completion rate and a significant reduction in no-show rates—around 15-20%—leading to substantial improvements in downstream revenue.
Make Smart Navigation your Competitive Advantage
Effective navigation isn’t a luxury—it’s essential. Health systems operating in competitive markets can’t afford to lose patients or potential revenue due to outdated navigation processes.
Care Continuity offers a clear path forward, transforming navigation from a chronic headache into a strategic advantage. By prioritizing the right patients, streamlining referrals, and enhancing communication across the enterprise, health systems can secure patient loyalty (and, by extension, improve customer lifetime value), maximize downstream revenue, and set the stage for sustainable growth and improved patient outcomes.
Care Continuity doesn’t just provide a one-and-done solution; it sets up health systems for sustained success. Its robust analytics framework tracks every granular detail, offering continuous feedback loops for improvement. By aligning service line growth, specialist capacity, and operational metrics, Care Continuity helps health systems adapt swiftly to changing market dynamics.
