Delivering quality service amid large member populations, strict regulations, and growing enrollment is a major challenge. When care is inconsistent, members may not receive the right treatment, miss follow-ups, or face avoidable hospital visits. Focus Care addresses this seamlessly, connecting care teams with real-time member information.
Research shows that continuity of care reduces hospitalizations in 89% of cases, decreases emergency room visits across all studies, and lowers mortality in 86% of cases. Reviewing millions of member interactions confirms that trusted relationships between members and care teams lead to reduced intensive interventions and less intensive care needs.
Creating Continuity of Care Systems
The solution lies in structured systems that improve information sharing, strengthen teamwork, and manage care more effectively. Secure health records ensure data moves safely and compliantly between providers, meeting HIPAA standards, while consistent case managers and care coordinators build trust and help members stay on track with their care programs. Proactive scheduling of check-ups, health reviews, transition programs, and follow-ups further keeps members engaged and promotes better health. Together, these methods create a strong foundation for continuity of care and support compliance with NCQA standards.
How Do We Approach Consistent Care?
Certified clinical teams perform in-home health assessments that screen for conditions such as diabetes, osteoporosis, vision issues, and high LDL, all in one visit. This enables health programs to identify and close care gaps under HEDIS and CMS Star Ratings.
Members are engaged through phone calls, text reminders, and digital outreach, while dashboards track key measures such as Continuity of Care Index (COCI) and Usual Provider Continuity Index (UPCI) scores, Healthcare Professionals Registry (HPR) ratings, and readmission rates.
We also improve communication between providers, caregivers, and members through secure technology that supports both in-person and virtual visits. This helps members transition smoothly across care settings. One health plan improved preventive visits by 27% in a single year with this approach.
Social determinants of health are also factored in, allowing care programs to be tailored to members’ unique needs. Data insights help identify at-risk members earlier, enabling timely intervention and fewer complications.
Building Stronger Systems for Health Plan Growth
Clients have cut 30-day readmissions by up to 35%, raised HPR scores from below 2.8 to above 3.2 in one year, and met NCQA quality needs. Member engagement rates often go over 75% in six months, leading to 30% drops in uncontrolled diabetes and hypertension care gaps. This means fewer ER visits, better adherence to care programs, and stronger results in value-based care systems. Health care teams benefit from reduced documentation thanks to proper reporting and easy records. For ACOs, this plan aligns preventive care with payment methods, creating a direct path to long-term clinical and financial success.
What Clients Say About Focus Care?
For years, our health programs struggled with ongoing challenges: members disconnected, unsupported, and uncertain. Satisfaction scores remained low, and progress seemed stalled.
That changed when they partnered with Focus Care. As the Program Director said,
“The structured approach from Focus Care has transformed our health programs. People in the programs feel more supported, and our scores have gotten better. With Focus Care, members now receive consistent, personalized care that feels like a true community, where every person matters, every concern is addressed, and every voice is heard.”
This transformation came from strategic planning, data-driven insights, and seamless coordination between providers. Communication gaps were resolved, follow-ups became consistent, and care delivery was unified. The result: stronger outcomes, higher satisfaction, and deeper trust between members and their care teams.
Strengthening Continuity of Care for the Future
Continuity of care is key to healthcare’s future. Adding structured programs ensures financial success and better member outcomes. Focus Care offers a data-driven approach that meets regulations, closes care gaps, lowers readmissions, and boosts satisfaction. By blending data, in-home and online visits, and easy provider teamwork, health programs can deliver caring, personal service while keeping quality high. Over time, these planned efforts grow long-term stability and trust, setting health organizations up to succeed in a results-driven, value-focused world. Partnering with Focus Care turns continuity of care from a challenge into a clear pathway for both present and future success.
Gregory Deranian
Gregory Deranian is Vice President of Business Development & Marketing at Focus Care, Inc, a leading national healthcare services company that partners with major health plans, ACOs, and physician offices nationwide to enhance quality of care for their Medicare, Medicaid, and ACA populations.