Care Gap Closure

Diagnostic Gaps

• Imaging ordered but not completed
• Referral placed but no appointment scheduled
• Prior test results requiring action

Care Gap Identification

Patient Cohort Query

CARE_GAP_QUERIES = {
    "lung_cancer_screening": {
        "criteria": {
            "age_range": [50, 80],
            "smoking_history": ">=20 pack-years",
            "smoking_status": ["current", "quit_within_15_years"]
        },
        "exclusion": {
            "prior_lung_cancer": True,
            "prior_chest_ct_12months": True
        }
    },
    "mammography_screening": {
        "criteria": {
            "gender": "Female",
            "age_range": [40, 75]
        },
        "exclusion": {
            "bilateral_mastectomy": True
        },
        "frequency": "Annual",
        "lookback_period": "12 months"
    }
}

Gap Detection Logic

def identify_care_gaps(patient_data, screening_guidelines):
    """Identify care gaps for a patient population."""
    
    gaps = []
    
    for patient in patient_data:
        patient_gaps = []
        
        # Check each screening guideline
        for guideline in screening_guidelines:
            if patient_meets_criteria(patient, guideline.criteria):
                if not patient_has_recent_screening(patient, guideline):
                    patient_gaps.append({
                        "patient_id": patient.id,
                        "gap_type": guideline.type,
                        "gap_reason": guideline.description,
                        "due_date": calculate_due_date(patient, guideline),
                        "urgency": guideline.urgency,
                        "intervention": guideline.recommended_action
                    })
        
        gaps.extend(patient_gaps)
    
    return gaps

Intervention Strategies

Outreach Tiers

OUTREACH_TIERING = {
    "tier_1_immediate": {
        "criteria": "STAT or urgent finding",
        "methods": ["Direct phone call", "Urgent message"],
        "timeframe": "Same day",
        "escalation": "If no response in 4 hours"
    },
    "tier_2_scheduled": {
        "criteria": "Routine screening due",
        "methods": ["Patient portal", "Letter", "Phone reminder"],
        "timeframe": "30 days before due",
        "escalation": "If no response in 14 days"
    },
    "tier_3_overdue": {
        "criteria": "Past recommended timeframe",
        "methods": ["Phone call", "Provider notification"],
        "timeframe": "On due date",
        "escalation": "Weekly for 4 weeks, then provider escalation"
    }
}

Patient Communication Scripts

# Care Gap Closure Phone Script

"Hello, may I speak with [Patient Name]?

My name is [Name] from [Facility]. I'm calling about your 
healthcare.

Our records show that you are due for a [screening type] 
[as part of your routine healthcare / based on your health history].

This screening is important because [brief reason].

How would you like to schedule this?

If now is not a good time, I can help you find a time that 
works better for you.

[If patient asks why]: This test helps [reason]. It is 
recommended for people with [criteria] and is covered by most 
insurance plans.

[If patient resistant]: I understand. Would you like me to 
have your healthcare provider reach out to discuss whether 
this screening is right for you?"

CLOSING:
"Great, let me help you schedule that now. [Proceed to 
scheduling] 

Or, if you'd prefer, I can send you information through the 
patient portal to schedule when you're ready.

Thank you for your time."

Gap Closure Workflow

Closure Documentation

CARE_GAP_CLOSURE = {
    "patient_id": "123456",
    "gap_type": "lung_cancer_screening",
    "identified_date": "2026-03-01",
    "outreach_attempts": [
        {
            "date": "2026-03-01",
            "method": "patient_portal_message",
            "result": "no_response"
        },
        {
            "date": "2026-03-08",
            "method": "phone_call",
            "result": "scheduled",
            "appointment_date": "2026-03-20"
        }
    ],
    "closure": {
        "status": "closed",
        "closure_date": "2026-03-20",
        "method": "completed",
        "study_type": "Low-dose CT Chest",
        "result": "Lung-RADS 2 - benign findings"
    },
    "notes": "Patient scheduled after one outreach call"
}

Provider Escalation

SUBJECT: Care Gap Escalation - Patient Not Responsive

Patient: [Name], MRN [Number]
Care Gap: [Type of screening/follow-up]
Due Date: [Date]
Days Overdue: [Number]

Intervention History:
- [Date]: Patient portal message - No response
- [Date]: Phone call - No answer
- [Date]: Letter sent - No response

Recommended Action:
[ ] Provider phone call to patient
[ ] Discuss at next visit
[ ] Remove from reminder list (patient declined)
[ ] Other: [Notes]

Patient Contact Information:
Phone: [Number]
Email: [Email]

Please advise on next steps.

Quality Metrics

Care Gap Dashboard

CARE_GAP_METRICS = {
    "identification_rate": {
        "description": "% of eligible patients with identified gaps",
        "calculation": "Patients with gaps / Eligible patients",
        "target": "Measure and report"
    },
    "closure_rate": {
        "description": "% of identified gaps that are closed",
        "calculation": "Gaps closed / Gaps identified",
        "target": ">80%"
    },
    "timeliness": {
        "description": "% of gaps closed within timeframe",
        "calculation": "Closed within standard / Total closed",
        "target": ">75%"
    },
    "patient_contact": {
        "description": "% of gaps with documented patient contact",
        "calculation": "Contacted / Gaps requiring action",
        "target": "100%"
    }
}

Reporting Template

# CARE GAP CLOSURE REPORT
## [Month/Quarter/Year]

### Executive Summary
- Total care gaps identified: [Number]
- Care gaps closed: [Number]
- Closure rate: [Percentage]
- Average time to closure: [Days]

### By Gap Type

| Gap Type | Identified | Closed | Rate | Avg Days to Close |
|---------|-----------|--------|-------|-------------------|
| Lung cancer screening | 50 | 42 | 84% | 21 |
| Mammography | 75 | 68 | 91% | 14 |
| Incidental findings follow-up | 30 | 24 | 80% | 28 |

### Interventions Used

| Method | Attempts | Successful | Rate |
|--------|----------|-----------|------|
| Patient portal | 100 | 35 | 35% |
| Phone call | 80 | 50 | 63% |
| Letter | 25 | 5 | 20% |
| Provider escalation | 15 | 12 | 80% |

### Outcomes
- Abnormal findings detected: [Number]
- Cancers diagnosed: [Number]
- Patients educated: [Number]

### Recommendations
1. [Priority improvement area]
2. [Secondary improvement area]

Related Skills

• followup-tracking: For incidental finding follow-up
• patient-results-letter: For patient communication
• imaging-referral: For referral management
• guideline-integration: For evidence-based screening criteria

Examples

Example 1: Identify Lung Cancer Screening Gaps

Find patients due for lung cancer screening who haven't been screened

query = {
    "screening_type": "lung_cancer_screening",
    "criteria": {
        "age": {"min": 50, "max": 80},
        "smoking_history": ">=20 pack-years",
        "quit_date": "none or <15 years ago"
    },
    "exclusions": {
        "prior_lung_cancer": True,
        "prior_chest_ct": {"months": 12}
    },
    "lookback": "12 months"
}

# Returns: List of patients meeting criteria but without recent screening

Example 2: Close a Care Gap

Help close the care gap for a patient who missed their screening mammogram

closure_workflow = {
    "patient_id": "123456",
    "gap": "mammography_screening",
    "steps": [
        {"action": "contact_patient", "method": "phone_call"},
        {"action": "schedule", "study": "digital_mammography"},
        {"action": "remind_prep", "info": "No deodorant day of"},
        {"action": "document_result", "status": "completed"}
    ],
    "outcome": {
        "status": "closed",
        "appointment_completed": "2026-04-15",
        "result": "BI-RADS 1 - Negative"
    }
}