As Carbon Health expands more into primary care, being good at following up with patient referrals becomes far more important as a lever to improve outcomes. When referring a patient, providers often highlight certain patients with urgent needs so our extended care teams can coordinate faster to address acute health issues.
Our existing referral process was born out of a workflow centered on urgent care; this workflow was optimized for acute referrals for a single problem. Primary, longitudinal care patients often collaborate with providers on multiple conditions, and in these cases, we’ve encountered a few problems.
• There was no way to view all referrals for a single patient in one place and understand or adjust based on how each was progressing.
• Every time our care coordinators had a task related to a referral, they needed to dig into the patient record to gain sufficient context to act.
• Care coordinators were unable to track the status of a referral as it moved between patients, team members, and specialists.
To solve these problems, we’ve shipped a “Care Adherence” tab into the provider application. This tab is viewable at a patient level in the patient chart, and it enables care coordinators to see what is happening with a patient referral, and to react and adjust as necessary.
• All referrals for a patient, and all care follow-up items for that specific patient, are hosted in the adherence tab.
• The tab enables care coordinators to execute several workflows, including moving a referral through each stage, and reassigning the responsibility for making or changing a decision to a provider or patient.
• It also enables all team members coordinating a patient’s care to understand the state of the specialist referral and make necessary changes to drive the best care outcome for the patient.
As always, please send questions or concerns here.