Now imagine this is occurring at your organization. If the patient follows up with a specialist outside of your network, you just leaked that case right out the door by not having a clear referral process. This could be because you lacked the technology to power it, especially if you’re a large or complex organization. Either way, under certain value-based care models, you just signed up to pay for the follow-up visit, imaging tests and labs, potential surgery and post-surgical care performed at a competitor’s facilities. If you’re operating a fee-for-service model, that leakage just cost your organization thousands of dollars of lost revenue.

Of course, there are further repercussions if the patient doesn’t follow up at all, which is not uncommon. After all, he’s feeling better for the most part, aside from being completely overwhelmed by trying to figure out what steps to take and where to go. So maybe he’ll just see how he feels after a few days before deciding to make an appointment (or not).

It’s also possible that in his rush to just get home he insisted he understood his discharge instructions but forgot them by the next day. So, after he was discharged from your ED and it came time to schedule his CT scan, he didn’t know what else to do other than make an appointment with a specialist he’d heard good things about. Who also happened to be outside of your network.

How the other half lives
The second patient in this example has an established primary care physician in your network. Outreach staff regularly check in on her records and care activity, making sure she gets her annual wellness exam, mammography appointment and flu vaccine. The focus is on keeping her as healthy as possible. For the sake of the example, let’s also say the second patient has diabetes. She works to manage her condition, but, like anyone else, she isn’t always perfect.

Her provider proactively monitors her stats and gets an alert when they’re outside the target range. When that happens, a clinician follows up with a phone call to ask how she’s doing. It turns out the patient isn’t feeling well. They see her primary care physician has an opening at 2 p.m. and book an appointment. Further, her record shows she doesn’t have a car or access to public transportation. The transport center orders a ride to pick up and drop off, which, at $12, is a bargain compared to multiple ED visits.

On the one occasion she does need to visit the ED (she’s fine, btw), your system’s central communications hub – something more than what many would consider a traditional transfer center – is able to route her records and information gathered during the ambulance ride to the ED so that staff don’t have to duplicate efforts. To further close the loop, clinical staff follow up with her after discharge to ensure she’s feeling well and following a plan to prevent another incident or readmission. When she needs to see a specialist, the right staff person sees that need within the system and proactively connects her to the right in-network facility and ensures her transportation needs are met as well.

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