For care coordinators
It’s 2:30. One question is still open:
Was the patient with the open gap here this morning?
The gap walked out the door, and nobody knew in time. We put the plan’s measures, gaps, refills and follow-ups in one list, with names, windows and next steps, so you know before they walk in.
Nothing to prepare · Nothing to sign · You decide after
The list is never in one place.
The plan’s report is in your inbox. The refills are in a portal that logs you out. The discharges came by fax. The gaps are in a spreadsheet only you understand. You work it one patient at a time, and when you’re out, it stops. Then the quarter closes, the score moves, and nobody can say exactly why.
You find out a measure slipped when it’s already been counted.
One list. Names, windows, next steps.
The plan’s quality and adherence files go in as they are and become call lists. Pickups are pulled in from the portal for the whole list at once. Hospital follow-ups have a window you can see before it closes. Patients coming in this week with an open gap are flagged before they arrive. Every call attempt is logged, so the work survives a day off.
Coming in this week
Open care gaps- Pat PatientsonEye exam still openTomorrow, 9:30 a.m.
- Sam PatientsonBlood sugar test still openThursday, 2:15 p.m.
- Alex PatientsonFlu shot, handled at last visitClosed
What changes for you
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The plan’s monthly report
Before
Hundreds of rows, retyped into a spreadsheet.
After
Goes in as it is, no retyping, and turns into lists with an owner and a log of every call attempt.
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The refill nobody picked up
Before
One portal lookup at a time.
After
Pickups pulled in from the portal for the whole list at once. Patients who can’t afford a medication are held and followed, not lost.
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The gap that walked out the door
Before
The patient came in for something else and left with the gap still open.
After
You see who’s coming in this week with a gap open, so it’s handled while they’re in the building.
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Hospital follow-ups
Before
The fax came Friday, and the window is already closing.
After
One owner, the next step and the days left in the window, tracked until it’s closed.
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The list that doesn’t match
Before
The plan’s condition list and your providers' lists drift apart.
After
Checked before the visit, so each condition is addressed accurately in the room and supported by the chart.
The quality work your plans pay for gets done, and counts. And you can see where it stands before the quarter ends, not after.
It’s the same system the front desk, the providers and the person who runs your day are already in. When a patient with an open gap is on today’s schedule, the provider sees it too.
Tell us which part of your quarter keeps catching fire.
Start with one. Nate will call within one business day.
Nothing to prepare · Nothing to sign · You decide after