Care gaps & Star Ratings
An open gap becomes a task somebody actually does.
Gaps come from your file. We rewrite them for an informal caregiver. Outreach escalates on a schedule and stops when the gap closes. Everything that happens comes back to you per measure.
How a gap moves
From a line in your data file to a completed appointment.
Every gap follows the same four stages: it arrives tagged to its measure, gets matched to a real person, gets rewritten into something doable, and reports back. One gap at a time, with a way out on every message.
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Ingest
Open gaps arrive from your member data on an agreed refresh cadence, tagged to the measure they belong to. Flat file or API, whichever your team can support.
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Match
Each gap is matched to the caregiver on record for that member. Members with no identified caregiver are reported back to you rather than silently dropped.
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Activate
The gap is rewritten into a plain-language action with a reason and a next step, then surfaced in the app on the escalation schedule below.
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Report
Outreach stops as soon as the caregiver marks the item handled, or when your next data refresh shows the gap closed. Either way, the activity reports back to you.
Anatomy of an action plan
What a measure looks like after we translate it.
You see that there is an Annual Wellness Visit open. The daughter managing her mother's care sees something she can do something about in under a minute.
- Progress, not nagging “You’re on track, 6 of 8 up to date” leads with what’s done. Caregivers who feel behind disengage; caregivers who feel competent keep going.
- The measure, in plain language “Yearly checkup with health questions” instead of the measure name. Nobody outside your building knows what an Annual Wellness Visit is.
- One primary action A clear action to move forward, whether that is scheduling an appointment or completing a survey.
- Why it matters A short explanation available on demand, for the caregivers who need a reason before they’ll act.
Escalation
One gap at a time, on a schedule that ends.
We surface the highest-priority open gap and leave the rest alone. Every step below is conditional on the gap still being open.
| When | Channel | Condition |
|---|---|---|
| Immediate | In-app message + push notification | New gap detected |
| Day 3 | Push notification, reminder | Still open |
| Day 7 | In-app prompt + push notification | Still open |
| Day 14 | Push notification, reminder | Still open |
| Day 21+ | Email, weekly | Still open, and frequency drops rather than rises |
| Any point | Outreach ends | Gap closed, marked already done, or member no longer eligible |
Target is closure within 21 days of first outreach. The first week of a caregiver's time on the platform is deliberately excluded, because we establish value before making any request. See the engagement model.
Measure coverage
Where caregiver action is worth the most.
A caregiver matters more on some measures than others. These are the ones where the outcome usually comes down to someone at home — booking the visit, keeping the follow-up, getting the kit back in the mail.
- Annual Wellness Visit
- Scheduling support and reminders through to a booked, completed visit
- Health Risk Assessment
- Guided completion with reminders and follow-up
- Breast Cancer Screening
- Scheduling support and reminders for the recommended screening
- Behavioral Health with Follow-Up
- Guided screening completion with automated follow-up actions
- Colorectal Cancer Screening
- Scheduling and at-home kit follow-through
- Controlling Blood Pressure
- Home readings, medication adherence, follow-up visits
- Osteoporosis Management
- Post-fracture follow-up and medication initiation
- Kidney Health Evaluation
- Lab scheduling and result follow-through
- Glycemic Status Assessment
- Lab scheduling, adherence, and follow-up visits
Which measures we take on, and in what order, is scoped with you during implementation.
Attribution & reporting
You see what the caregiver did, for whom, after which outreach.
Caregiver engagement is easy to claim credit for and hard to prove. The reporting is built so you can check our work rather than take our word for it.
Caregiver activity by measure
Every caregiver action tracked against the gap it belongs to and rolled up by measure, with the outreach that preceded it. Closure itself is confirmed in your data, not declared in ours.
Funnel and engagement
Caregivers identified, contacted, onboarded, and active, so you can see where the funnel leaks rather than only what came out of it.
The same activity we bill on
Billable events are the events in the report. Reconciling an invoice means reading an activity log you already have, line by line.
Bring your measure list.
A 30-minute working session on which of your gaps a caregiver can realistically move, and what a pilot would look like.
Request a demo