Source: https://ensurecare.ai/resources/media/care-pathways-between-visits

> One care plan, four handoffs after the visit: a referral, a prescription, a follow-up, and a prior authorization. See where each can stall and lead to the ED.

Video · CAIR Platform

# Where care breaks down between visits

One care plan, four handoffs after the visit: a referral, a prescription, a follow-up, and a prior authorization. See where each can stall and lead to the ED.

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## Transcript

1. Care depends on what happens between visits. John’s care plan has four parts. Each one happens after he leaves.
2. A referral isn’t closed when it’s sent. John has to reach the cardiology practice, get a visit booked, and show up. Any handoff can stall. The pathway only closes when the visit notes reach his primary care doctor.
3. Prescribed isn’t the same as understood, or taken. Does John know when to take each one, and which reactions to watch for? If he misses a dose, will anyone know?
4. John’s follow-up is due in six weeks. He misses it. The next opening is twelve weeks out. In that gap, John may end up in the ED.
5. His treatment needs prior authorization. The payer reviews the documentation. If it’s denied, John’s treatment waits on an appeal. A denial can become another care gap.
6. The care plan exists. So where does care break down? Open handoffs lead to the ED. After discharge comes a new care plan, and a higher readmission risk. Each time around, costs rise and John’s health declines.
7. See where care gaps happen, and how to close the loop. Visit ensurecare.ai to learn more.

Length

1:25

Type

Video

Topic

[CAIR Platform](https://ensurecare.ai/platform)

[See how the CAIR Platform works](https://ensurecare.ai/platform)

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