Closing care gaps with AI: a guide for health plans and providers

Many patients who miss a screening or a follow-up visit haven't decided against it. They forget, can't find a time that works, aren't sure it's covered, or never hear back after a reminder they couldn't reply to. Each of those is a care gap, and many can be closed with the right conversation.

What is a care gap?

A care gap is the difference between the care a patient should get under clinical guidelines and the care they've actually received. Health plans and providers find gaps by comparing claims, lab results, and medical records against recommended care for each patient's age, sex, and conditions.

Common care gaps include:

• Overdue cancer screenings, such as mammograms, colorectal screening, and cervical cancer screening
• Missed recommended A1c monitoring and retinal screening for patients with diabetes
• Missing recommended follow-up after a hospital discharge or emergency department visit
• Potential medication-adherence gaps, after checking for prescription changes or discontinuation
• Missed recommended vaccinations and, for eligible Medicare beneficiaries, annual wellness visits

Why closing care gaps matters

Closing appropriate care gaps can help prevent disease, detect conditions earlier, and improve chronic-condition management. The benefits vary by audience:

• Patients: Receive recommended care that can help prevent complications and support better health.
• Health plans: Improve performance on relevant HEDIS measures and Medicare Advantage Star Ratings, which can affect quality bonus payments.
• Providers: Keep patients up to date on recommended care and meet quality goals tied to value-based contracts.

Why traditional outreach leaves gaps open

Most care gap programs rely on mailers, one-way text reminders, and outbound call teams. Each has limits:

• One-way messages can't answer questions. A text that says "You're due for a mammogram" doesn't tell the patient whether it's covered, where to go, or how to book.
• Call teams have limited capacity. Staff can only make so many calls a day, and they often call when patients can't pick up.
• Follow-up is inconsistent. If a patient doesn't respond, the next attempt may come weeks later, or not at all.
• Barriers go unaddressed. Cost, transportation, language, and fear stop many patients. Those come up only when someone asks and listens.

How AI agents help close care gaps

An AI agent can coordinate outreach and scheduling when connected to the necessary systems, from first contact to a booked appointment, for every patient on a gap list. It works through these steps:

1. Pick who to reach. The agent starts from gap lists built from claims, EHR, and quality reporting data, and prioritizes patients by risk, due date, or measure.
2. Reach out on the right channel. It contacts patients by text, phone, or email, and tries again on a different channel or at a different time if they don't answer.
3. Answer the questions that stop people. It explains what the test or visit involves, whether the patient's plan covers it, how to prepare, and where to go.
4. Book the appointment in the same conversation. It checks provider availability, schedules the visit, and sends reminders. If the patient misses it, the agent reaches out to reschedule.
5. Address practical barriers. It can arrange transportation benefits, offer a language the patient prefers, or send a home test kit where one is available.
6. Escalate when needed. If a patient mentions new symptoms or asks a clinical question, the agent routes them to a nurse or care manager under your clinical protocols.
7. Record the result. It writes outcomes back to your systems, so your team can see which gaps closed and which patients need another approach.

Because the agent can follow a patient over days or weeks, outreach doesn't end after one missed call. Each conversation also adds context, such as the times a patient prefers or the barrier they mentioned, that makes the next contact more likely to work.

Example: a mammogram outreach program

Here's how a single outreach might go for a health plan member who is overdue for a screening mammogram:

1. The agent texts the member to say she's due for a screening and asks if she'd like help booking.
2. The member asks whether it will cost anything. The agent checks her plan’s benefits and explains her expected out-of-pocket cost.
3. The agent offers available appointments at in-network imaging centers near her home and books the one she picks.
4. It sends a reminder with the imaging center’s preparation instructions the day before.
5. If she misses the appointment, the agent follows up to reschedule. Once the screening is completed and documented, the screening gap is marked closed. Any abnormal results require separate clinical follow-up.

How to measure a care gap program

Measure whether patients receive the care they need, not just how many messages the agent sends. Track three steps:

• Patients reached: How many patients responded to outreach?
• Appointments booked: How many scheduled the recommended care?
• Gaps closed: How many completed the care, confirmed by a qualifying claim or medical record?

Use these results to identify where patients need more support. If patients respond but don’t book, look at scheduling barriers. If they book but completion remains low, check for missed appointments, long wait times, or delays in receiving records.

Track the time from first outreach to completed care to understand how quickly the program helps patients close gaps.

Compliance and safety requirements

Care gap outreach involves protected health information and outbound calls and texts, so the agent has to meet the same rules as your existing programs:

• HIPAA. Verify the patient's identity before sharing health details, and keep conversation data protected.
• Consent for calls and texts. Contact patients only through channels and numbers they've agreed to, and honor opt-outs right away.
• Clinical boundaries. Define which questions the agent answers and which it routes to clinicians, and log every handoff.
• Audit trails. Keep a record of every message and action so compliance teams can review them.

Sierra's Compliance Console lets healthcare organizations set these rules across channels, use cases, and states.

Getting started

1. Pick one gap with a clear measure, such as breast cancer screening or diabetes eye exams.
2. Check that your gap list is accurate and current, so the agent doesn't contact patients who already got care.
3. Connect the agent to scheduling, eligibility, and your record systems, so it can answer questions and book in the conversation.
4. Set your clinical escalation rules and consent requirements before launch.
5. Track gaps closed each week, then expand to more gaps once the first program works.

Healthcare organizations including The Cigna Group use Sierra to carry context across voice, chat, and other channels, so patients get to the right care sooner.

Read more about how healthcare organizations use AI agents.