Connecting Physicians to the Full Continuum of Care

Updated on June 4, 2024

Physicians have become increasingly pivotal players in the success of value-based care. According to a 2023 physician survey conducted by WellSky, 59% of respondents are currently in value-based programs, and 75% of respondents see participation in these programs increasing going forward. By 2030, the Centers for Medicare and Medicaid Services (CMS) has stated an intent to align all Medicare fee-for-service beneficiaries in care relationships that are accountable for quality and the total cost of care. Imperative to the success of these models is the ability to collaborate with providers across the continuum.

Not surprisingly, most physician care teams lack even basic visibility to where their patients are receiving care, creating gaps in critical information and care. For example, physicians often do not find out that their patients were hospitalized and subsequently discharged to a nursing home until weeks after the fact. Similarly, they may be unaware of a patient’s visits to urgent care centers or specialty clinics, further hindering their ability to intervene when appropriate. Without real time data, care teams miss out on opportunities to intervene in key moments in the patient’s care and could lead to unnecessary hospital readmissions and poor patient outcomes.

A critical component of enabling value-based care is equipping the practices of today with technology to transform them into the next-generation providers of tomorrow. Technology today can push targeted patient data at key moments – for example an emergency department visit or hospital discharge – to physician care teams. Keeping physicians in the loop helps to ensure that care transitions are coordinated and that patients receive services such as transitional care management (TCM) visits that have been shown to reduce readmissions. According to WellSky’s physician survey, 57% of respondents reported an inability to conduct TCM visits due to challenges such as a lack of timely data, technology, and staffing constraints. Access to up-to-date and accurate information enables physicians to take a proactive approach to patient care.

Going together with visibility is actionability. Technology is needed to both provide transparency into acute and post-acute settings of care and enable collaboration with those care teams at critical moments in the care journey. For example, 90% of respondents in WellSky’s physician survey indicated that they send referrals to home and community-based organizations manually (by fax or phone call). Manual workflows increase inefficiencies and staff burden, taking valuable time away from patient care. Nationally, one-third of referrals to home health originates from physicians in the community, highlighting the significant role physician’s play in facilitating seamless transitions and continuity of care for patients beyond the clinical setting. Both physician and home care teams benefit from shared technology that enables referrals, bi-directional communication, and facilities care coordination activities on shared patients.

When physicians are empowered with real-time data to proactively engage and intervene with patients at critical moments in their care journey, they are better able to build trust with their patients and improve outcomes. This not only strengthens the patient-physician relationship but also contributes to higher levels of patient satisfaction. Patients feel supported and well-cared for no matter where they are in the care continuum, and providers can ensure their patients receive the right care at the right time.

With the right technology, physicians can enhance their decision-making with timely patient data and greatly extend their care coordination capabilities by enabling coordination with external care teams. There are many steps in the road to delivering high quality and value-based care, and equipping teams with foundational tools is one key step along the way.  By leveraging technology to support proactive engagement, physicians can foster stronger patient-physician relationships, optimize care delivery, and ultimately achieve better health outcomes for their patients.

Dr. Lissy Hu copy
Dr. Lissy Hu
President of Wellsky's connected networks at WellSky

As president of WellSky’s connected networks, Dr. Lissy Hu works with leading health systems, payers, and accountable care organizations to optimize post-acute care outcomes. In 2012, Lissy founded CarePort to provide care coordination software solutions to manage patient transitions across the continuum. CarePort’s end-to-end platform bridges acute and post-acute EHRs — providing visibility for providers, payers, and ACOs into the care that patients receive across care settings. Lissy earned her Doctor of Medicine from Harvard Medical School. She holds an MBA from Harvard Business School and a BA in pre-medical studies and sociology from Columbia University.