A large integrated health system identified an opportunity to improve how patients with advanced heart failure (AHF) are connected to specialty care. Referral timing varied across care settings and often depended on individual provider recognition, limiting early intervention and reducing visibility into patients not yet established with specialty teams. This made it difficult to consistently surface high-risk candidates and ensure timely follow-through.
To address this, the client defined a more proactive
approach—anchored by an advanced heart failure scoring model and a reimagined role for Epic in driving earlier
identification and standardized referrals. Pivot Point
Consulting partnered to operationalize this vision, translating it into an embedded Epic workflow with registry logic, referral prompts, and real-time dashboards across care settings. The result was a unified, workflow-driven model connecting clinical criteria directly to action at the point of care.