When a Clinic Phone Line Became a Barrier to Care

The Challenge

Imagine being discharged from the ED and relying on a clinic you can’t reach for the follow-up care you urgently need. Recently, Care Continuity’s Navigator team identified exactly that issue, stemming from recurring communication barriers with a top-tier specialty clinic at a leading health system in the Midwest. Calls to the clinic were being picked up and immediately disconnected, making it extremely difficult to consistently reach the office and coordinate patient care. 

What We Did

Our navigators engaged with hundreds of cardiology referrals and tracked the pattern over several months, escalated concerns, and continued supporting patients who needed follow-up. The urgency became clear during a sensitive case involving a patient managing both colitis and kidney stone complications. After two days of outreach attempts, Navigators were able to connect the patient to care — but the situation reinforced how even small communication barriers can directly impact timely care, clinical outcomes and patient loyalty.

The Impact

• Coordinated with clinic and client leadership to identify the root cause of the issue
• Implemented operational improvements to address underlying scheduling barriers
• Introduced an alternative workflow to maintain access to follow-up care
• Ensured ED patients could receive timely follow-up while the clinic stabilized its phone and scheduling processes

Why It Matters

We ensured the patient received the critical follow-up care they needed while identifying and resolving the underlying barriers in the health system medical group hand-off process. These improvements now help future patients access timely follow-up care, reducing delays, stress, and administrative burden.