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CHRONIC CARE MANAGEMENT

Your Quality Gaps Won’t Close Themselves

Chronic patients drive the largest share of open quality measures. Diabetic eye exams, A1C testing, blood pressure control, medication adherence, cancer screenings. When your chronic population doesn’t follow through, your star ratings pay the price.
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THE CHALLENGE

You Can See the Gaps. You Can’t Close Them at Scale.

You know which quality measures are lagging. You can see the gaps in your reporting dashboards. The problem isn’t visibility. It’s capacity to do something about them at scale.

Closing quality gaps requires proactive outreach to patients who need specific services completed. For chronic populations, that means reaching patients with diabetes who haven’t had their A1C tested, patients with hypertension whose blood pressure isn’t controlled, patients overdue for cancer screenings, and patients who stopped filling prescriptions three months ago.

Your quality team can identify these patients. But reaching every one of them, having the conversation, scheduling the right appointment, removing whatever barrier is keeping them from completing the action, and confirming closure requires dedicated staffing that most organizations don’t have.

The result: gaps stay open. Star ratings stagnate or decline. Payer bonuses shrink. And the patients who need the most attention get the least because the system doesn’t have capacity to reach them.

ROOT CAUSE

Open Quality Gaps Are a Signal That Your Highest Risk Patients Are Falling Through

  • Quality gaps concentrate in your chronic population.

    Patients with multiple chronic conditions account for a disproportionate share of open measures. They also account for the majority of your avoidable utilization, readmissions, and downstream costs. The same patients whose gaps are dragging your star ratings are the same patients who end up in your ED when their unmanaged conditions deteriorate. Closing gaps isn’t just about compliance. It’s about preventing the utilization events that drive your cost structure.

  • Reactive gap closure doesn’t work at scale.

    Most organizations attempt gap closure through annual or quarterly campaigns. Staff pull lists, make calls, schedule appointments. It works for the easy cases. But the patients with 5+ open gaps, the ones with transportation barriers, language barriers, medication confusion, and no established relationship with a care manager, don’t respond to a campaign call from someone they’ve never spoken to. They need consistent, trusted outreach over time. That’s what CCM is designed to deliver, when it’s structured around activation instead of compliance.

  • Disconnected gap closure and care management waste both efforts.

    If your quality team runs gap campaigns separately from your CCM program, patients get called twice for different reasons by different people reading different scripts. Neither interaction builds the trust or continuity needed to actually change behavior. The work duplicates. The outcomes underperform.

OUR APPROACH

Quality Gap Closure Built Into Every CCM Touchpoint

We integrate quality gap closure directly into CCM outreach. Every monthly touchpoint is an opportunity to identify open measures, schedule the right service, and confirm completion.

  • Gap aware outreach at every CCM call

    Our workflows flag open quality measures for each patient before the call begins. Specialists address clinical needs and quality gaps in the same conversation, not as separate campaigns.

  • Activation, not notification

    We don’t just tell patients they’re overdue for an A1C. We schedule the lab, address the transportation barrier, and confirm the appointment is completed. The gap closes when the action happens, not when the call ends.

  • Consistent monthly contact builds trust that campaigns can’t

    Patients respond to someone they know. Our model creates a consistent relationship with each enrolled patient, making gap closure conversations natural extensions of ongoing care management rather than cold outreach.

  • Connected across care management models

    CCM, PCM, AWV, and TCM touchpoints all contribute to gap closure. One team. One relationship. Multiple opportunities to complete the measures that matter.

See our full Chronic Care Management approach

RELATED CHALLENGES

Related Challenges

PROVEN AT SCALE

From open gaps to activated chronic populations

We turn monthly CCM touchpoints into closed quality measures and completed care actions.
99.4%
Quality KPI pass rate
~100%
Appointment adherence
35%
Fewer readmissions
31%
Higher patient satisfaction

Close the gaps your team can’t reach at scale

See how activation driven CCM outreach turns monthly touchpoints into closed quality measures.

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