Between visits
Care gap outreach that closes gaps between visits.
Patients with open gaps and nothing booked, called, booked and closed on record.
Open gaps with no visit on the books
| Patient | Status |
|---|---|
| Maria L. | Working |
| James O. | Working |
| Priya S. | Working |
| Daniel R. | Working |
| Ana T. | Working |
Patients already booked are skipped. A gap closed by staff stays closed.
Open care gaps are missed care and missed quality revenue. Closing them keeps panels healthy and schedules full without adding staff.
Every
open gap with no visit booked, called
0
duplicate calls to patients already booked
What care gap outreach means here
Care gap outreach is the work of finding every patient who is due for a measure, has nothing booked, and has not been reached, then getting them on the schedule. 2care does that work from your own lists and records, and marks the gap closed when the record shows it.
Most practices already know where the gaps are. The payer sends a list, the EHR holds recalls, and the dental schedule shows treatment that was planned and never finished. What is missing is the hour a day it takes to call through it all.
Care gap closure depends on that follow through. A list nobody calls closes nothing, and a gap that was addressed but never reconciled still counts against you.
Where the gaps come from
Five sources, one list to work.
Gaps arrive from payers, from your EHR and from your own clinical data. They are matched to the patient and merged, so each open gap appears once.
From source to worklist
- 1
Payer list
HEDIS pre-chart import
- 2
EHR recall
As set by your team
- 3
Computed recall
Last visit plus interval
- 4
Treatment plan
Unscheduled CDT items
- 5
One worklist
Matched, merged, deduped
Inactive patients are excluded before anything is sent.
Payer quality lists
Import the pre-chart lists payers send for HEDIS care gaps. Each row is matched to a patient in your system before it joins the worklist.
EHR and computed recalls
Recalls set in your EHR come across as they are. Where none exists, a recall is computed from the last visit and the interval you set.
Dropped treatment plans
In dental, planned items that were never scheduled become gaps, one per CDT category, so a patient with three unfinished items gets one conversation.
The outreach sequence
Call, text, call again, then a person.
Each open gap moves through a short sequence you configure. It stops the moment the patient books, opts out or is found already scheduled.
Annual wellness visit, James O.
Call
phoneDay 0No answer, generic voicemail left
Text
smsDay 2Booking link with three open slots
Call
phoneDay 5Second attempt in the evening window
Flag for staff
Day 8Attempts and notes attached
Sequence stops on booking, opt out or an existing appointment.
On the call
Identity first, then the gap, then a slot.
The patient confirms who they are before anything clinical is said. After that the call is about one thing: a time that works.
Outbound call, annual wellness visit
Maria L.
Call in progress
Hi, this is the scheduling line at your doctor's office. Can I confirm your date of birth?
Sure, it's March 4th, 1958.
Thanks, Maria. You're due for your annual wellness visit. I have Tuesday the 12th at 9:20 or Thursday at 2:40.
Tuesday morning is good.
Done. Tuesday the 12th at 9:20 with Dr. Patel. I'll text you the details now.
Booking written to the schedule, confirmation sent by text.
The privacy rule
What gets said, and what gets skipped.
A care gap is health information. The rules that decide what is said on each contact are fixed, and they run before every call and text.
Before naming the gap
Result
Name the gap and offer slots
Otherwise: generic voicemail, skip, or refill reminder.
The difference
The same gap list, worked two ways.
The list is identical. What changes is whether anyone has the hours to call through it.
Worked by the front desk
Worked by 2care
When the list gets called
In the gaps between phones, often the week before the deadline
Every day inside your calling window
Patients already booked
Called anyway, because nobody cross checked
Skipped, the schedule is checked before each step
Patients who never answer
One voicemail, then forgotten
Call, text, second call, then a flagged task
Gaps addressed in a visit
Still open until someone updates the sheet
Closed by reconciliation against your records
Seeing where you stand
A spreadsheet rebuilt for each payer report
A closure rate card and a CSV export by measure
Tracking care gap closure
Closure by measure, on one card.
The worklist keeps a running closure rate by measure, so you can see which gaps are moving and which need a different approach.
Example: gaps closed by measure this quarter
Illustrative figures for layout only, not customer results.
See it work
The patients who never came back
Working a recall list the front desk never has time for, and putting the lapsed patients back in the diary.
Between visits
The rest of the workflow.
Before you hand over the gap list
What quality leads ask about gap outreach.
Any measure in your catalog. Common ones are the annual wellness visit, A1c and blood pressure follow ups, cancer screenings, immunizations and dental perio maintenance. Each measure carries a handling type, so a lab gap, a referral gap and a medication gap are each worked in the way that actually closes them.
From the payer quality lists you already receive, recalls set in your EHR, recalls computed from a last visit plus an interval, unfinished dental treatment plan items, and quality measures calculated from your own clinical records. They merge into one worklist so a patient is never contacted twice for the same gap.
Yes. Payer pre-chart lists for HEDIS care gaps can be imported directly, matched to your patients and worked alongside your own recalls. The closure is recorded against the measure, so the payer list and your record tell the same story at the next reporting cycle.
Nothing clinical. The call introduces the practice and asks the patient to confirm who they are. Only then is the gap named. Voicemails never mention a test, a condition or a screening, only that the practice would like a call back.
Three ways. A booked visit moves the gap to booked. A reconciliation run closes it when your records show the qualifying code inside the look back window. Or your staff close it by hand with a disposition, and a human close is never reversed by the system.
Yes. You set the calling window, the days, the number of steps and the channels. Patients who opt out are removed, inactive patients are excluded, and anyone with a visit already scheduled is skipped until that visit passes.
Yes. Calls and texts run in English and Spanish, using the language preference on the patient record where one is set.
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