Opportunity

Patients often receive important follow-up recommendations – such as imaging or specialist visits – but these next steps do not always occur. As a result, serious conditions can go undetected or untreated, even when patients have ongoing contact with the health system. This gap in follow-through can lead to worse health outcomes, increased burden on clinicians to track outstanding care, and greater legal and operational risk for the system.

This moment in the care journey is critical: Delays in follow-up can mean missed opportunities to intervene early, when conditions are more treatable. Improving how patients are identified and supported after a concerning finding creates an opportunity to close this gap, ensuring that important recommendations lead to timely care rather than getting lost over time.

Intervention

High-Risk Follow Through is a centralized program that helps identify patients with overdue, high-risk care recommendations and supports them in completing the next steps. It combines data, technology, and a care team to proactively find patients who need follow-up and guide them through scheduling and completing recommended care.
 
Once a patient is identified, High-Risk Follow Through uses a combination of outreach methods – including text messages, phone calls, and clinician reminders – to prompt and assist with scheduling. Patients who need additional support can be connected to a centralized clinic or offered virtual visits if they do not already have a care team. This coordinated approach helps ensure that patients receive timely follow-up while reducing the administrative burden on clinicians.

Impact

High-Risk Follow Through launched in April 2025 and operates across the health system. Initially we have focused on patients with needing follow-up imaging for lung nodules, and we are working to expand the program to more clinical areas such as surveillance colonoscopies.
 
As of May 2026, the program has supported nearly 8,000 follow-up interventions, leading to more than 1,300 completed CT scans for pulmonary patients and the detection of 12 cancer cases.

By improving how patients are identified and guided to complete recommended care, the program is increasing access to timely services, enabling earlier diagnosis of serious conditions, and helping the health system better capture and coordinate care across a growing set of clinical populations.