Why Continuity of Care After Health Assessments is Critical for Health Plan Success

Health assessments are often the first meaningful connection between health plans and their members. They provide a unique opportunity to identify risk factors, document chronic conditions, and uncover social determinants of health (SDOH) that impact access to care. But while they are a critical first step, health assessments are only the beginning of enabling ongoing, whole-person care. To improve outcomes and member engagement, health plans need a continuity of care strategy that guides members beyond a one-time assessment into ongoing support.

In this blog, we share how health plans can build a continuity of care strategy that turns assessments into action and drives measurable results.

Why Continuity of Care Matters for Health Plans

Continuity of care is more than tracking a member’s health status over time. It’s about building sustained, trusting relationships between members, their primary care providers, and care teams. When members engage consistently with their providers, they are more likely to follow care plans, complete preventive visits, and feel confident managing chronic conditions.

For health plans, continuity of care delivers meaningful results:

• Improved Quality and Compliance: Ongoing follow-up helps close gaps tied to Star Ratings, HEDIS measures, and other quality programs.
• More Accurate Risk Adjustment: Regular engagement ensures conditions are documented consistently and accurately.
• Stronger Member Engagement & Retention: Proactive outreach and support builds trust and reduces churn.
• Lower Avoidable Costs: Timely follow-up reduces preventable emergency visits and hospitalizations.
• Better Provider Collaboration: Sharing actionable data strengthens relationships with PCPs and makes care coordination more effective.
  
  

Proactive continuity of care strategies help close gaps tied to Star Ratings, HEDIS measures, and other quality programs.

How to Strengthen Continuity of Care After Health Assessments

Building a strong continuity of care strategy requires thoughtful, personalized approaches. Here are proven tactics that help turn assessments into action:

• Personalized Outreach: Timely, relevant communication is essential. Following up with members through calls, texts, or emails helps them understand their assessment results, feel supported, and take the next steps to schedule recommended care.
• Education and Resources: Clear, culturally appropriate materials help members understand their conditions and why follow-up is important. Education empowers members to engage confidently in their care plans.
• Accessibility and Transportation Support: Many members face barriers to getting to follow-up appointments. Offering transportation assistance or telehealth options helps ensure they complete needed care.
• Building Relationships: Building a trusted relationship between members and care teams is critical. Health plans can utilize case management or care coordination teams to support members and use SDOH data to inform personalized engagement strategies.

Social determinants like transportation, housing, and health literacy often prevent members from completing care. Personalizing outreach helps remove these barriers.

The Role of PCPs

Primary care providers play a critical role in delivering continuity of care. Engaging PCPs early and sharing health assessment data in a clear, actionable format makes it easier to coordinate follow-up and keep members connected to their care teams.

Strong partnerships with PCPs can:

• Streamline transitions from assessments to care planning.
• Support timely referrals and preventive screenings.
• Reinforce trust and consistency in the member’s experience.

When health plans and providers collaborate, members are more likely to complete follow-up visits, manage chronic conditions effectively, and feel supported throughout their care journey.

Missed follow-up visits can lead to higher avoidable costs, including preventable emergency room visits and hospital admissions.

How Advantmed Supports Continuity of Care

At Advantmed, we believe health assessments should create meaningful connections that drive member engagement and better outcomes. Our approach helps health plans strengthen continuity of care through dedicated follow-up calls that support members in scheduling PCP visits, accessing resources, and staying engaged in their care journey. As a trusted partner, we work alongside plans to deliver a more connected, effective experience that supports the full lifecycle of care.

Continuity of care is not just about completing a one-time health assessment. It’s about sustaining engagement over time, ensuring members receive timely follow-up, and moving beyond simply tracking health status to providing ongoing support throughout the full lifecycle of care.

– Doug Wackowski, VP of Prospective Service Solutions, Advantmed

Conclusion

Continuity of care transforms a health assessment from a single encounter into an opportunity to build lasting trust, improve outcomes, and deliver a more connected experience for every member. By combining proactive outreach, strong PCP partnerships, and clear follow-up strategies, health plans can close critical gaps and support whole-person care at every stage.

Explore these strategies in more depth in our on-demand webinar, Beyond the Assessment: Driving PCP Visits Through Continuity of Care.