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The space between visits
Published by
Thyme Care
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A perspective from Thyme Care
Most health systems already have a navigation team. Most have a care management program that includes an after-visit summary and a patient portal. On paper, the space between the time the patient leaves your office to their next visit looks handled.
But even in high performing clinics, staffed by people who care as much about getting things right as anyone in the field, there is a gap that consistently goes unclosed. Patients leave the exam room after what feels like a thorough conversation, then come back weeks later with almost no memory of what had been explained about their own prognosis. The system is well built to manage patient needs in-person. But what about everything that happens between visits?
"We have a navigation team" is not the same as "The gap is closed"
Treatments have progressively improved over the past decade and patients are living longer with cancer than ever before. As a result, cancer care models continue to evolve to adjust to patient needs. Whether we’re talking about treatment regimens managed at home or programs designed to manage psychosocial or financial hardship needs, all of that is ultimately good news for the patient. It is also a lot more for any one clinical team to track, including a strong navigation program.
Most oncologists already sense how much goes unseen in a patient’s care journey, and the research supports it. Close to 60 percent of people with cancer say they are unwilling to raise a symptom directly with their clinical team.1 Left unaddressed, symptoms that go unmanaged can end up in the ED. More than half of cancer-related emergency department visits are considered potentially preventable, and the number of those visits grew from roughly 1.8 million to 3.2 million between 2012 and 2019.2 Adherence tells a similar story. Published estimates suggest 40 to 60 percent of women with breast cancer stop adjuvant endocrine therapy before completing five years, and stopping in the first year has been linked to a substantially higher risk of breast cancer–related death.3
These numbers point to a specific, structural gap, not a failure of any navigation team’s effort. It’s the space no team can fully see, no matter how strong their program is, because it lives outside the walls of the clinic. Closing it looks like fewer unnecessary visits and more of the scheduled care a patient’s own oncology team already provides, delivered at the moment it is needed, in the right site of care.
What most care management programs are missing
Before Thyme Care existed, most oncology programs relied on care management outreach solutions from outside vendors that struggled to meet their needs. A patient would come in and mention that someone had called them about their care plan, but there was no record or coordination in place to know who that person was or what they were trying to accomplish. What was missing was coordination, the connection between the outreach and the oncology team that makes it possible to actually close the gap.
That experience shaped how Thyme Care works. Support between visits only works when it is designed with the oncology team, not around it. Before we start working with a health system partner, we learn what the team already does well, including who calls a patient first after a treatment visit, which symptoms they already track closely, and what their workflows look like. From there, we define each team’s role together, with the patient’s experience at the center, so support is coordinated by design.
During a recent live conversation with Becker’s Hospital Review, Dr. Brian Dorsey, who leads Clinical Innovation and Delivery Design at Thyme Care, shared an example of how a partner oncology practice had a strong transitional case management program that was reducing readmissions. Though two gaps remained. The program was not staffing discharges for chronic conditions alongside cancer, and it could not see admissions at hospitals outside its own system. Thyme Care’s nationwide admission feed lets us see admissions outside its system. The practice kept primary responsibility for oncologic discharges, and Thyme Care took primary responsibility for comorbid discharges and out-of-system admissions. As a result, their providers were able to offer better support because they knew what was happening to their patients outside their own care setting.
That is how support between visits earns its place in a team’s workflow. The health system leads where it is strongest, we fill the gaps it cannot see, and the physician stays informed in the EHR they already use, so nothing about a patient’s care between visits is a surprise to the person who knows them best.
The bottom line
Support between visits helps health systems keep patients on their treatment plans, reach them before a symptom becomes an emergency, and see what is happening outside the clinic, without adding work for the teams already caring for them.
Closing this gap starts with coordination designed alongside the practice from day one, so every team knows its role and the patient hears one coordinated voice.
The right technology puts what we learn between visits inside the EHR a clinician already uses, so the care team has the information when it matters.
Longer treatment journeys, rising pharmacy complexity, and a workforce that is growing more slowly than demand are structural realities. No single health system created them, and meeting them takes partnership, with support built to extend the teams already doing this work.
Thyme Care’s leadership team discussed this in depth with Becker’s Hospital Review, including how health systems are extending support between visits without adding to their teams’ workload.
