What comes in
Open care gap
- Follow-up identified as overdue
- Outreach approved by the practice
Care Gap Agent
Find overdue care. Follow through with the patient.
Caesar identifies open quality measures in your patient records and runs the outreach to get patients booked. Your care team sets priorities and reviews the evidence that a gap is closed.
- Turns open measures into outreach work
- Tracks completion evidence in the record
See the work
Booking is progress. The record confirms completion.
Illustrative examples of overdue care and a result that needs to be reflected in a measure.
What comes next
Appointment arranged
- Patient contacted
- Visit scheduled for follow-up
The appointment is recorded. The measure remains open until completion is supported.
What Care Gap Agent does
- 1Find gap
- 2Reach patient
- 3Book visit
- 4Check completion
What comes in
Result in the record
- Measure still marked open
- Relevant completion record available
What comes next
Measure review
- Evidence matched to the measure
- Status updated when requirements are met
The quality record reflects documented care.
What Care Gap Agent does
- 1Read result
- 2Match measure
- 3Check evidence
- 4Update status
What it handles
Work the gap while there is time to act.
A quality report tells you what is open. Caesar connects that finding to the outreach and records work needed to follow it through.
Find open measures
Review connected patient records against the quality measures configured for your practice and flag missing evidence of completion.
Prioritize the work
Organize open gaps using your program's priorities so your care team can focus its outreach.
Reach the patient
Contact patients about overdue care and connect them with scheduling. Keep unsuccessful outreach visible for follow-up.
Track the result
Look for completion evidence in the connected record and update the measure status when its requirements are met.
Fits your practice
Make each open measure actionable.
Define the program and outreach scope with your care team. Measure requirements and clinical priorities guide the work.
- 1
Choose the measures
Set the quality measures and patient population your practice wants to work.
- 2
Review the records
Identify gaps using the data available through your connected EMR.
- 3
Coordinate outreach
Use approved messages and scheduling pathways to contact patients.
- 4
Confirm the evidence
Track results against the measure requirements before recording closure.
Your clinicians decide what care is appropriate.
An open measure is a signal to review, not a treatment decision. Your team handles clinical exceptions and patient preferences. A booked appointment alone does not prove a quality measure is complete.
- Clinical priorities set by your care team
- Closure based on documented measure requirements
Keep your existing system.
We confirm the available connections and functions in your electronic medical record system, or EMR, before setup.
Check your EMR integration
Available functions vary by system and agent.
Before you start
Your questions, answered.
What to expect from Care Gap Agent, and what your team controls.
Which quality measures does the Care Gap Agent track?
It tracks HEDIS, MIPS, Medicare Stars and ACO measures using the applicable NCQA and CMS specifications. Measure logic is maintained as specifications change, with year-round checks of the patient panel. The configured measures and data sources are confirmed for your program.
How does it decide which patients to work first?
Open gaps can be stratified by clinical risk and likelihood of closure under your program's rules. For example, a patient with diabetes and an overdue A1C can be prioritized for review. Your clinicians decide what care is appropriate and handle exceptions.
Does it replace our panel managers?
No. Your panel managers and quality team own the program. Caesar handles recurring chart review, risk stratification and routine outreach, leaving unresolved gaps and patient conversations with the team.
How does a closed gap get reflected in our scores?
The agent checks new screening, lab or follow-up records against the measure requirements and updates the quality dashboard through the connected system. Completion evidence can come from structured records or extracted outside documents. A booking alone does not close the measure.
Which EHRs does it integrate with?
It reads structured and unstructured clinical data in supported EHRs including Epic, athenahealth, eClinicalWorks and NextGen, and can write closure status back. Your available data determines which measures can be worked.
Is the Care Gap Agent HIPAA compliant?
Yes. The Care Gap Agent runs on HIPAA-compliant infrastructure. Data is encrypted in transit and at rest. Caesar Health executes a Business Associate Agreement (BAA) at contract signing. SOC 2 Type II is in progress.
How does it reach patients and notify clinicians?
Approved outreach uses SMS, email or phone to connect overdue patients with scheduling. Open gaps can also be shown to the provider at the point of care. Contact attempts and unresolved requests stay visible for follow-up.
Does care gap software include population analytics and incentive tracking?
Yes. Reporting tracks measure performance across the patient panel and progress toward quality-contract targets. It can show incentive opportunities alongside open gaps, while your team confirms the evidence and program requirements for any reported completion.
Care Gap Agent
Start with the measures you need to work.
We will map an open gap to outreach, scheduling and the evidence needed to record completion.
Book a demo