Establishing a Framework for Gold-Standard Longitudinal Care

Three Insights for Specialty Practices

By Shirley Lee, CRNP-FNP, MPH

Keeping patients from falling through the cracks due to breakdowns in care efficiency is one of the toughest challenges specialty care practices face—especially during a pandemic. It requires access to the right information at the right time to ensure patients receive the appropriate follow-up care. It also necessitates a framework that prompts and supports proactive communication while enabling clinicians to work within their scope of care.

When specialty providers think about longitudinal care—efforts to meet patients’ whole-health needs at each point in their care journey—their first thought is typically the resources required to pull it off. Ideally, longitudinal care examines not just the impact of a diagnosis on the individual, but also the risk for family members (e.g., “Should a cancer patient’s children undergo gene testing?”). It also seeks to answer: “What matters most to the patient?” Digging into these questions takes time and manpower.

Longitudinal care efforts can feel daunting, especially when multiple providers are involved. However, with the right support framework—and the data to determine where to focus first—specialty practices can bolster care coordination and follow-up. Doing so not only improves outcomes, but also enhances access to care and strengthens engagement.

Here are three considerations for designing a framework to provide gold-standard longitudinal care—informed by data—that most effectively meets patients’ needs:

1. Empower care navigators and medical assistants to proactively reach out to patients whose health may be at risk. It’s no secret that the number of individuals delaying recommended screenings, lab tests, or follow-up care increased during the first year of the pandemic. Often, this occurred as people sought to avoid exposure to the coronavirus in healthcare settings. But for some classes of patients, delayed care may have nothing to do with fear of COVID-19. These include women who are overdue for cervical cancer screenings—a trend that began to take shape before the pandemic. Some experts anticipate there will be a surge in advanced cancer cases due to the persistent lack of timely screenings and diagnoses. Without a framework for proactive communication with patients, specialty care practices could be ill equipped to deal with such a surge.

That’s why empowering care navigators and medical assistants to proactively check in with patients who could be at higher risk for progression of disease or complications—many of whom face multiple conditions—is critical. Increasingly, specialty care practices are investing in AI-powered software solutions that comb through medical records to identify categories of patients who could benefit from a call with a clinician. These solutions then prompt clinicians to reach out to patients and provide condition-specific questions to guide conversations. When physician attention is needed, the software automatically alerts the clinician.

At Anne Arundel Urology, based in Annapolis, Maryland, an AI-powered approach to closing gaps in care helped detect cancer progression in nearly two patients per month, information that let those patients receive vital care sooner. It also enabled the practice to identify 69 new treatments for 61 patients in one year—even while saving providers 10–15 minutes per patient in data review. Furthermore, the practice simultaneously generated an additional $76,000 in chronic care management revenue while strengthening care for patients.

2. Ensure team members properly triage patients based on their symptoms, medical history, and more. Establishing a clinical framework for determining when to escalate patients for follow-up care helps speed access to a physician when patients need it most. This gives patients with complex diseases, like cancer, their best chance for optimal outcomes. Similarly, providing the infrastructure for following evidence-based care pathways gives clinicians the confidence that they are making the right moves for patients’ health.

At the Greater Los Angeles Division of Genesis Healthcare Partners, P.C., a urology-specific care navigation platform helped medical assistants identify 125 patients with chronic cystitis who could benefit from a remote cystitis clinic. When these patients experience symptoms of a urinary tract infection (UTI), medical assistants order a lab test that is more effective at detecting a UTI than a traditional dipstick analysis or urine culture. Within 12 months, the remote clinic helped 110 patients avoid urgent or emergency care.

3. Standardize priority risk assessment. This enables patients with critical needs to receive immediate attention from physicians and other care specialists. It also eliminates the inefficiencies that can occur when team members bring too many cases to physicians’ attention because the team members don’t have the tools to judge the severity of the patient’s illness. At Genesis Healthcare Partners, for example, standardized protocols inform next steps in care for patients with chronic cystitis, including whether to refer patients directly to the remote cystitis clinic. This approach has reduced costs of care for these patients while generating $69,000 in chronic care management revenue.

A more modern approach to care coordination

Developing a framework for longitudinal care is complex work, but it’s a task made easier by tools and processes that standardize care protocols and clinician response across settings. By making the right investments for evidence-based decision-making, specialty care practices can coordinate patient care more effectively and efficiently, ensuring patient treatment plans are executed safer, faster, and with better outcomes.

Shirley H. Lee, CRNP-FNP, MPH, is vice president of clinical strategy for Preveta, a care coordination platform for specialty care. She is also the director of a patient navigation program and a nurse practitioner for the Greater Los Angeles Division of Genesis Healthcare Partners, P.C. Lee is a graduate of the Johns Hopkins School of Nursing and Johns Hopkins Bloomberg School of Public Health.