Closing Care Gap Navigator gaps faster with mobile workflows, Epic-
connected data, and
practical AI

Client Challenge

A typical Medicaid MCO serving 220,000 Medicaid and Children's Health Insurance Program members was struggling to close HEDIS gaps efficiently.

Care managers worked across Epic, paper notes, calls, and field visits. Field teams had no mobile access. Many members needed outreach in Spanish or through low-bandwidth channels.

The result: slower outreach, duplicated work, missed closure windows, and care teams spending too much time on documentation.

The client needed to reduce physician burnout while maintaining care quality and work around Epic limitations without raising flags.

A HEDIS gap is a missing or incomplete healthcare quality action — like a screening, lab, or follow-up — needed for a patient to meet HEDIS care standards.

Solution Delivered by Zfort Group

Zfort Group built a Care Gap Navigator that
complements Epic, not replaces it.

The platform gives care teams:

01
Real-time care gap visibility
02
EHR Data Integration and Normalization on Epic FHIR
03
Mobile-first workflows for field care managers
04
Offline documentation with sync on reconnect
05
English and Spanish support
06
SMS and app-based communication tools to reach populations in their preferred channel
07
A population health dashboard for quality teams

The goal was simple: help care managers know who to call, why now, and what action to take.

AI-Assisted Care Management

Zfort added an AI/ML layer to prioritize closable gaps.

Instead of a generic risk score, the model predicted which member gaps were most likely to close with timely outreach.

01
Predicts which gaps are most likely to close
02
Ranks members by expected closure impact
03
Shows why each member is recommended
04
Suggests best outreach channel and timing
05
Flags gaps nearing the end of the measurement window
06
Helps reduce documentation time — EHR data entry is the #1 complaint

Generative AI was not placed in the clinical critical path. Templates and recommendations were clinically reviewed before use.

Security &
Compliance

Built for sensitive payer and clinical data:

01
HIPAA-aligned architecture
02
BAA-covered AWS services only
03
AI/ML pipelines for US payers under BAA
04
Role-based access control
05
PHI redaction in logs
06
Encrypted data at rest and in transit
07
Audit-ready workflows
08
Secure Epic FHIR integration

Results & Impact

After the first full measurement year:

+5.4 pp *GSD closure rate
+5.1 pp *BCS-E closure rate
+2.8 pp *CBP closure rate
24% lower cost-to-close per gap
1.7x higher care manager throughput
Internal care manager *NPS rose from 24 to 56
Field visit documentation moved from 4-24 hours later to real-time offline-then-sync

The platform helped the client reduce *MLR without cutting care: population health risk models + care management tools.

*GSD is Glycemic Status Assessment for Patients With Diabetes
*BCS-E is Breast Cancer Screening
*CBP is Controlling High Blood Pressure
*Net Promoter Score
*MLR is Medical Loss Ratio

Why It Matters

For Medicaid plans, care gap closure affects quality scores, contract bonuses, NCQA readiness, member outcomes, and MLR.

Zfort helped the client close the digital experience gap with mobile-first, multilingual, accessible member portals and care team tools.

The same architecture can scale rapidly to new acquisitions without rebuilding technology each time.

Zfort HealthTech Advantage

After the first full measurement year:

Build tools that complement Epic, not replace it
EHR optimization and Epic limitations handled from day one
HIPAA- and SOC 2-aligned delivery
Secure mobile care management platforms
HEDIS and population health automation
AI-assisted care prioritization
Analytics and measurement infrastructure that tracks quality measures, cost outcomes, and population health improvements across acquired health systems