Care gaps & Star Ratings
An open gap becomes a task somebody actually does.
This is the mechanism in detail: how gaps reach us, how they get rewritten for a family member, how outreach escalates and stops, and how the resulting activity reports back to you at measure level.
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.
A quality team sees “Annual Wellness Visit: open.” The daughter managing her mother's care sees something she can act on in under a minute.
- Progress, not a scold “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 single button that starts the work, which here means scheduling. Choice is the enemy of completion.
- Why it matters A short explanation available on demand, for the caregivers who need a reason before they’ll act.
- An honest off-ramp “Already done” and “Remind me later” stop the outreach. Letting people out is what keeps the channel trusted.
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.
Not every measure benefits equally from a caregiver. Four have complete action plans running today. The other five are measures where we think the family member is the deciding factor, and where the action plan is still being built.
| Measure | Caregiver action | Status |
|---|---|---|
| Annual Wellness Visit | Scheduling support and reminders through to a booked, completed visit | Action plan live |
| Health Risk Assessment | Guided completion with prompts and follow-up reminders | Action plan live |
| Breast Cancer Screening | Scheduling support and reminders for the recommended screening | Action plan live |
| Behavioral Health with Follow-Up | Guided screening completion with automated follow-up actions | Action plan live |
| Colorectal Cancer Screening | Scheduling and at-home kit follow-through | In development |
| Controlling Blood Pressure | Home readings, medication adherence, follow-up visits | In development |
| Osteoporosis Management | Post-fracture follow-up and medication initiation | In development |
| Kidney Health Evaluation | Lab scheduling and result follow-through | In development |
| Glycemic Status Assessment | Lab scheduling, adherence, and follow-up visits | In development |
Which measures we take on, and in what order, is decided with you during implementation. We would rather run four properly than nine at half strength, and we will say plainly which is which before anything is committed.
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