Continuity deserves a place between appointments

Recognition for work between visits

CMS announced its 2025 Medicare physician fee schedule final rule (opens in a new tab) in November 2024. The new advanced primary care management services included elements such as:

“24/7 access and continuity of care”

— Centers for Medicare & Medicaid Services, November 2024

These were payment arrangements for qualifying services beginning in 2025, with requirements that participating practices needed to understand. The announcement did not mean every practice had introduced a new round-the-clock service.

A dependable contact between visits needs more than a telephone number. People need to understand the offer, and the team needs enough capacity to honor it.

The question that arrives after the visit

Consider a hypothetical participant who leaves an appointment with an agreed next step. Several days later, they are unsure which team is arranging a follow-up conversation.

They do not necessarily need another full appointment. They need to know whom to ask, through which channel, and what response to expect.

From the organization’s perspective, the answer may seem obvious. From the participant’s side, several telephone numbers and messages may look equally plausible. Continuity becomes visible in how that ordinary uncertainty is handled.

Define the offer before promoting it

A service should explain what its contact route is for and which team receives the message. Response expectations need to match the actual arrangement.

Distinguish routine administrative questions, clinical concerns, and urgent situations using guidance approved by the responsible professionals. A general information channel should not accidentally imply that it is monitored for urgent care.

Give colleagues the same explanation participants receive. If reception, a clinician, and a partner organization describe the offer differently, people may make plans around a promise that nobody intended.

Make responsibility survive an absence

A familiar contact can be reassuring, but continuity should not disappear when that colleague is away. The organization needs an authorized way for another person to understand the relevant next step.

Decide which information belongs in the appropriate professional record and which practical update can be shared through another permitted channel. More copying is not automatically better coordination.

In our example, the participant should not have to reconstruct the entire history simply to learn who is arranging the next conversation. Equally, a colleague should not be expected to act on information they are not authorized or qualified to interpret.

Give the work enough room

Responding, checking, documenting, and following through all take time. A continuity offer should be supported by staffing and processes, not added as an invisible duty between appointments.

Ask how demand will be reviewed and who can adjust the arrangement when it exceeds capacity. A growing queue may reveal a mismatch between the promise and the resources behind it.

Qualified billing and clinical leads must decide how any new payment arrangements apply. The service-design conversation then needs to connect those decisions to the work colleagues actually perform.

Ask what continuity means to the person

Some people value a familiar voice. Others mainly want a clear answer without repeating themselves. A participant may want a chosen supporter involved or prefer to handle the conversation privately.

Ask about communication preferences and explain the available options. A digital channel can be convenient, but it should not be assumed to suit every person or every question.

When the organization changes a contact arrangement, tell people what will happen to an outstanding request. A new telephone number or message system should not leave them wondering whether the earlier question has been lost.

A supporting connection through genus today

Configured genus care apps and care walls can provide program information, appropriate conversations, tasks, and prepared resources. Organizations can use those features to make an agreed contact route and practical next steps easier to revisit.

genus does not create a clinical access service, establish Medicare billing eligibility, or replace professional records and urgent-care arrangements. Those responsibilities remain with the organization and qualified providers.

The useful contribution is to support an offer that has already been defined. Technology can make a contact easier to find; people, capacity, and clear ownership make the contact dependable.

Review the arrangement with the team receiving those contacts. Their experience can reveal unclear messages, repeated transfers, and information that would help people choose the right route sooner.

A question before making the promise

When someone reaches out between visits, can we explain who will respond, what they can help with, and what happens if the usual person is unavailable?