How to close care gaps without hiring a team of 10

Healthcare organizations are under increasing pressure to close care gaps, yet doing so at scale has traditionally meant adding more staff. Annual Wellness Visits, cancer screenings, diabetic care, immunizations: the sheer volume of preventive and chronic care needs can overwhelm teams that are already stretched thin. 

Every unclosed care gap represents a missed opportunity to prevent illness or manage chronic conditions early, leading to worse outcomes for patients and higher costs for providers.

But now, thanks to intelligent automation, it’s possible to radically improve care gap closure without hiring a larger team. 

Here’s how leading health systems are using digital workflows powered by AI Agents to close more care gaps with fewer resources, while also delivering better patient experiences and measurable outcomes. 

Building an intelligent workflow: From chart scrubbing to outreach

1. AI chart review and scrubbing

Traditionally, when human staff couldn’t get to all patient charts in a timely manner, they either had to randomize which charts they were reviewing, prioritize high-risk patients, or forgo the work completely. 

Now, Intelligent Agents can automatically scan patient records across both structured and unstructured data, identifying open gaps and extracting relevant details for providers. They can quickly confirm which care gaps are truly open and flag any documentation that’s missing or misfiled, for entire patient populations. 

Once the data is clean, outreach becomes far more effective, with fewer false positives, higher engagement, and better clinical outcomes. 

2. Automated care gap outreach

Once charts have been scrubbed and patients with care gaps have been identified, AI Agents can engage patients directly about specific overdue screenings or preventive visits, such as colonoscopies, mammograms, or Annual Wellness Visits. 

The outreach is personalized, multi-lingual, and can be sent in a patient’s preferred communication method: via SMS, email, or voice call. It’s triggered by real-time EHR data to book appointments and catch missed opportunities for improved patient outcomes. 

Voice AI, in particular, is purpose-built to take on these time-consuming phone calls that have typically bogged down staff. AI Voice Agents can reach out proactively to close care gaps, communicating with patients with empathy and clinical fluency at any time of day that is convenient for them. With Voice AI, health systems see high patient engagement, task completion, and the ability to handle complex, end-to-end workflows. 

With AI Agents, there is no need for call center staff to manually comb through lists or pick up the phone to close care gaps; they can simply handle inbound escalations instead.  

3. Pre-visit clinical screening and chart prep

Before a patient’s visit, automated workflows can collect data like health risk assessments, symptom checklists, or digital screeners through mobile-friendly forms. These data points are summarized and written into the EHR as pre-populated notes, so the provider walks in already prepared with context and action items prioritized. 

This proactive prep improves the quality and efficiency of the patient visit, increasing the likelihood that care gaps are closed during the encounter and that patients are receiving the level of care they expect from their provider. 

4. Quality metrics collection and real-time reporting

AI Agents can track the resolution of care gaps over time and automatically generate internal or external reports on quality performance. These real-time dashboards replace manual spreadsheet input and allow leaders to quickly see which populations are underserved and which interventions are working. 

Real world impact: What automation enables

Healthcare organizations automating care gap workflows have unlocked outcomes not previously possible with human staff alone.

Montefiore, a New York-based health system comprising 10 hospitals and over 200 outpatient ambulatory care sites, has reviewed over 50,000 charts across its system, increasing its care gap closure rate from 3-4% to 7% and identifying more than 4,000 incremental gap closures that would have otherwise remained open. Accuracy in documentation exceeds 95%, and 4,000+ hours of staff time have already been saved. The automation has delivered $400,000 in ROI on just $60,000 in product utilization, an impressive 6x return. 

Importantly, these gains aren’t limited to the highest-risk 10% of patients or a random sampling. Organizations like Montefiore are able to scale personalized outreach and follow-up to tens of thousands of patients, offering equitable, proactive care across populations while maintaining staffing levels.

Rethinking resources: It’s not about adding headcount

What used to require a large team of chart reviewers, outreach coordinators, and reporting analysts can now be achieved through intelligent automation. AI Agents don’t just run in the background – they operate 24/7 and follow protocols to the letter. 

Far from replacing your team, they elevate it, creating space for caregivers to focus on conversations, decisions, and care that truly require a human touch. 

Contact our team to learn more about intelligent care gap closure and new ways health systems can scale sustainably.