Program · runs under quality / population health
Care gaps & preventive careThe list already exists. The phone labor is why it is not worked.
Patients your gap list already identifies as overdue, who are not being worked because working them is manual phone labor.
The gaps
The gaps it works off your own list.
These are the measures your quality team already reports on. The program does not invent the list — it works the one you have, one patient and one gap at a time.
Breast cancer screening
Explained in plain terms, booked in the same conversation
Colorectal cancer screening
Including the objection nobody records: what the prep involves
Cervical cancer screening
Due dates the patient never knew existed
Diabetic eye exams
The gap most often open longest on the diabetic panel
Annual labs
The blood work the next visit depends on, done before it
Immunizations
Season by season, against what the record shows is due
Blood pressure follow-up
The recheck that was ordered and never scheduled
Bone density screening
Eligible for years, never once asked
Which gaps are worked, in what order, and how many attempts before a patient is marked unreachable is configured by your quality team at go-live. And when a patient raises a symptom mid-call, the outreach becomes an escalation — transcript attached, gap still open.
The contact
What each contact follows.
Worked against the gap list on the schedule the quality team sets, with a defined number of attempts before a gap is marked unreachable.
Every attempt ends as a recorded outcome — so who was actually reached this month is a fact your team can pull, not a guess.
Voice call · one patient, one gap
“Your records show a screening that's due this year. I can look at what's open over the next few weeks — would mornings or afternoons suit you better?”
Followed on every contact
- The specific gap that is open for this patient
- Why it matters, in terms that make sense to them
- What the objection actually is when they decline
The split
The routine part completes on the contact. The rest reaches the care team.
Completed without a clinician
- Offering times and routing the booking
- Recording a real reason for declining, rather than an unanswered call
Text message · same outreach, other channel
Sent to the care team
- A symptom that surfaces during the outreach and is unrelated to the gap
- A patient whose circumstances mean the gap should not be worked as written
An escalation arrives with the transcript, the triggering sentence, and the change against this patient’s own baseline — in the patient’s own care team’s queue, ranked by severity.
The escalation rules are written and certified by our clinicians before any patient is contacted. How programs are designed.
The list, after
Every attempt ends in an outcome, not an attempt count.
Booked, declined for a recorded reason, escalated, or honestly unreachable — and every one of them writes back to the gap list your quality team already reports from.
Care gaps · outreach outcomes
Worked this week
Every outcome writes back to the gap list your quality team already reports from.
Running the program
- What it writes back
- The outcome of the outreach against the gap, so the list reflects work done rather than attempts made.
- Who owns it on your side
- Quality / population health. Every outcome lands back on the list that team already reports from — work done, not attempts logged.
- What a pilot measures
- Gaps closed per hundred worked, and the share of attempts that produced a real outcome rather than an unanswered call. Agreed before the pilot starts — the only honest form of proof we offer.
Bring the gap list you already report on.
You know which measures are behind. The conversation worth having is what it would mean to have every patient on that list reached, with a real outcome recorded.
Talk to our team