HEDIS Gap In Care Proactive Outreach

Hi Team,

I would like to ask your experience in regards to HEDIS Gap in care proactive outreach process. We have access to our patients who have gaps in care through our consortium’s Tableau system and we make sure that we assigned specific department that can do outreaching and remind patients about the need to do their health screenings.

In this note, we have a noted a dilemma for our childhood immunization. In order for us to meet the HPL we have to have 3 patients complete their immunizations. We generated the list and we only have a total of 6 qualified patients for this measure.

What we have done so far:

  1. Called the patient’s parents and remind them about their child’s immunization
  2. Only 1 patient has completed their immunization and the other 5 patients either they have moved to another county or have new PCP
  3. We have reached out to our consortium and provided our situation and requested to give us a new list however they stated that if there is an opportunity for this request they will let us know asap

I just want to know how did you manage to resolve this issue if you have experienced it in your health center.

Thank you and looking forward to your responses.



Great question @rtanglao. I’m wondering if our coaches may have an idea of other teams working on a similar issue? @Carolyn_CCI_Coach @Denise_PHLN-Coach?

I’m tagging some teams that might have an answer to this: @Neighborhood @NEVHC @Venice @NEMS.

Hi Ryan!

We have ran into similar situations where we will have a patient in our Gap In Care report in Tableau, but they have either relocated or are seeing a PCP outside of our clinic. After touching base with CHCN, we were advised to reach out to the patient(s) directly and to request them to notify their payor of the update (which seems like the only way for the patient to drop off from our Gap In Care report). Based on previous efforts, it does not seem like a lot of these patients actually followed up and therefore, they end up being a part of the denominator and are labeled as “not actionable.”

Branching off of Ryan’s inquiry, if anyone has any suggestions on best practices on closing the loop here - I too would be interested.


Hi Ryan
This is frustrating and I am sure you have many colleagues who can relate and hopefully chime in. When I worked for Medi-Cal Managed care plans, we heard this frustration from clinics. Our solution, albeit not great, was to have the clinics contact the health plan while the patient was in the office (or via a conference call if calling in) to make a PCP change. I know it still puts the burden on the clinic, but this was something I heard from clinics was helpful especially because there was a specific person at the health plan in member services they could call to make the switch and eventually, all folks in member services were trained so clinics could call the number and get any member services rep to help out.


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We have staff whose whole job is to reach out proactively to clients with gaps in care, but have had minimal success reaching out to clients. We use phone calls, texts, and emails. While we do have the added burden of being unable to clearly identify we are calling from the LGBT Center for safety reasons, I can’t imagine that is tge whole story.

We are changing tactics to address gaps via a huddle sheet so we can catch as much as we can when tge clients are in front of us.

I would love to hear what outreach is effective for othe clinics

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Besides the phone calls, we have also used mailers as well as emails. Beyond the communication channels we also found that including incentives helped close the gap. Movie tickets and/or gift cards were used as an incentive. We felt there was a danger in getting our patients used to “getting a prize” for taking care of their health but it did help. It was also key to include our Outreach Team in the external efforts. We coordinated their efforts with school outreach as well.

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@rtanglao @Afsheen_AXIS @tammy_cci @mkavanagh @adrian_neighborhood

Seeing that there’s interest in alternative methods of reaching patients, I wanted to share an upcoming CCI webinar on texting and how to use it to help with outreach, patient scheduling and managing your patient populations between visits:

Texting for Better Health

Join us on Feb. 15 at noon PT as we discuss texting. You will learn:

  • How to use texting in conjunction with patient scheduling.

  • How to use texting to engage and manage a complex patient population between visits.

  • How to use texting as an outreach tool for targeted populations.

This webinar latest installment of our digital health e-learning series. It’s hosted by Raven, CCI’s learning laboratory to discover, pilot, and connect digital health solutions.

DATE: Friday, Feb. 15, 2019

TIME: 12pm PST


Register Now


Ray Pedden
Strategy & Innovation Consultant
Center for Care Innovations

Julie Edgcomb
Ambulatory Services Administrator
Monterey County Health Department

Stephen Gutierrez
Chief Information Officer
Northeast Valley Health Corporation

Adriana Velez
Outpatient Services Manager
Monterey County Health Department

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