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PCP-to-Specialist Referral Management

PCP-to-Specialist Referral Management

PCP-to-Specialist Referral Management

5 verified clients
PCP-to-Specialist Referral Management
PCP-to-Specialist Referral Management


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Avia Summary

PCP-to-Specialist Referral Management is a solution provided by Care Continuity which was founded in 2008. It belongs to multiple categories of digital health solutions including Smart Hospitals, Care Transitions, Referral Management, Concierge Care, Personalized Care, and Conversational AI.
It has 5 verified clients.
PCP-to-Specialist Referral Management integrates with major EMRs such as Epic, Cerner, and Meditech.
Some other resource(s) that may be helpful in learning about PCP-to-Specialist Referral Management include: Mytonomy guide: Selecting a Modern Enterprise Patient Education Solution and A buyer’s guide to conversational AI

Care Continuity's PCP-to-Specialist Referral Management is a data-driven patient navigation designed to increase PCP-to-specialist completion rates and improve utilization of your aligned provider network by improving appointment completion rates for your most profitable service lines.

Care Continuity leverages a purpose-built software that utilizes AI and machine learning to analyze dozens of data points and social determinants of care that make it possible to prioritize patients for outreach based on their need, and to maximize the downstream effectiveness of a patient navigation program. In addition, the software is supported by a team of trained concierges that do the navigating on your behalf, allowing your team to continue working at the top of their license.

In addition to higher specialist attachment rates, health systems that utilize Care Continuity's PCP-to-Specialist program gain valuable insights into their network performance. Curated data dashboards provide an in-depth look at referral appointment completion percentages, procedure-to-appointment rates, median times to appointment, and more. This data can also be viewed at the service line and facility level, giving actionable insights into potential areas for growth.

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Product capabilities


Care Continuity's software solution support bi-directional integration with the ability to ingest applicable data from a health system's EHR, as well as repopulate any applicable system post-navigation.

What is interoperability?
Conversational AI solutions should seamlessly integrate with the EHR and other existing systems, databases, and digital channels.
EHR integration

Acute care EMR, Ambulatory EMR, Ancillary EMR, ERP system, Patient portal, Pop health platform
Epic, Cerner, Meditech, Allscripts, NextGen, athena, GE, eClinicalWorks, McKesson
Not applicable
Use cases and differentiators

A health system is looking for ways to drive more patients to their cardiology service line. Historically, cardiology has been one of their more profitable service lines. With a provider network featuring multiple facilities and other service lines, the system has struggled to track the downstream progress of a patient after their primary care referral. 

Leveraging Care Continuity's PCP-to-Specialist Referral Management solution, a data feed of referrals is sent to Care Continuity where the software's AI uses dozens of data points -- including diagnoses, discharge notes, patient information, social determinants of health, and more -- as well as a set of customizable prioritization rules to create a navigation queue for a team of expert navigators to personally contact and navigate.

This allows for a multi-dimensional approach to patient navigation that can predict which patients are most in need of, as well as open to, navigational assistance. 

The trained team of navigators contact the patients based on their priority ranking and can coordinate the specialist appointment between both patient and office. On average, a patient navigator can schedule a higher percentage of appointments at a faster rate when compared to other self-navigation methods. In addition, appointments scheduled via a patient navigator are statistically less likely to result in a no-show. 

After the program is implemented, health system stakeholders receive a data dashboard that shows the downstream impact of the navigation, including the total number of appointments scheduled, the number of completed appointments, the number of appointments that required procedures, and median time to appointment. 

With this data broken down by both service line and facility, a health system can focus on a profitable service line such as Cardiology, looking for areas to improve their network and make a positive financial impact. 

Medium to extra-large health systems

Leading EHR functionality takes a very basic approach to patient navigation. When utilized, the EHR prioritization queue is binary, labeling every patient as urgent or non-urgent. Instead, Care Continuity not only expands the total number of evaluated data points needed to properly prioritize a patient, but Care Continuity also expands the priority listing to 10 levels, allowing for a more nuanced and tailored navigational experience. 

In addition, the EHR functionality requires the health system to staff a team of navigators. Unfortunately, this largely non-clinical function is staffed by clinical staff, severely hampering their ability to work at the top of their license. 

Care Continuity pairs their purpose-built software with a team of trained, non-clinical concierges who are experts in patient experience and proper navigation.

With more than a decade of experience working with the nation's leading health systems, Care Continuity has had the honor of navigating millions of patients through the healthcare continuum. 

Leveraging purpose-built software with proprietary algorithms designed to efficiently navigation patients, Care Continuity can provide a customizable, high-ROI solution for health systems of any size.

Company information

Founded in 2008



Sample Referral Dashboard
Sample Referral Dashboard - by Service Line
Patient Navigation Shouldn't Be-One-Size-Fits-All
Prevent Patient Leakage with AI
The Benefits of Data-Driven Patient Navigation
ROI-Minded Approach to Patient Navigation

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