This case study outlines the success of a data-driven patient engagement initiative that closed critical preventive care gaps across six clinical categories. The outreach leveraged Epic’s campaign functionality, enabling patients to seamlessly schedule an appointment to close their care gaps by clicking a secure link within their message. This streamlined process reduced barriers to action and empowered patients to take immediate steps toward completing recommended preventive services.
Missing preventive screenings and unmanaged chronic conditions increase both health risks and costs for the patients and employers. Preventive care compliance remains a key challenge for community health services operating under fee for service models due to higher patient volumes and shorter visits.
The QuadMed health care model transforms primary care from a reactive, visit-based service into a strategic health partnership by using initiatives to address care gaps. The outreach campaign is designed to re-engage patients, close care gaps, and improve quality performance metrics aligned with CMS and HEDIS measures.
This initiative focused on populations with the greatest impact on overall quality scores and cost exposure — those overdue for cancer screenings, flu vaccinations, and diabetic A1c testing. All outreach was designed to be compliant, empathetic, and centered on the patient experience.
Each campaign segment was developed using curated lead lists drawn from electronic health record (EHR) quality registries. Over a four-month time period, patient outreach was conducted through secure patient portal messaging, to drive completion of overdue services ensuring privacy and compliance while optimizing engagement. Campaign success was measured by care gap closure, defined as the documented completion of the recommended screening, test, or visit.
Together, breast, cervical, and colorectal cancer screening campaigns closed 186 care gaps achieving an average conversion rate of 16%. Each completed screening represents both a meaningful health improvement and a financial benefit through early detection and reduced treatment costs.
A ‘lapsed patient’ was defined as an individual who had not completed a recommended preventive service or attended a primary care visit within the past 18 months. Targeted outreach to this group achieved a 15.8% conversion rate, demonstrating the effectiveness of proactive re-engagement in restoring active care relationships. These reconnections improve adherence, increase preventive service completion, and recapture revenue while helping to reduce avoidable emergency department utilization.
Although newly launched, the A1c Overdue campaign delivered meaningful early results, closing five diabetic care gaps and helping prevent potential complications, along with costs from avoidable ER visits and hospitalizations.
The flu vaccination campaign reached 1,080 patients, closing 44 care gaps with zero opt-outs, an indicator of positive patient sentiment. Preventive vaccination strengthens both individual health and supports workforce productivity, particularly during peak flu season.
The success of this initiative underscores the power of data-driven, empathetic patient engagement in achieving both clinical and financial goals. By integrating predictive analytics, direct patient communication, and provider follow-up, the team converted nearly one in ten outreach leads into completed preventive action, a rate well above industry benchmarks for population health campaigns.
Beyond improving quality metrics, the campaign demonstrated how preventive care translates directly into financial stability within value-based reimbursement models. The approach proved scalable, sustainable, and well-received by patients, setting a strong foundation for future outreach efforts in 2025 and beyond.
The outreach campaigns achieved their dual mission: improving patient health while delivering measurable value. By closing 284 care gaps, the organization advanced preventive care compliance, strengthened population health outcomes, and generated an estimated $180,000 in total impact.
The initiative provides a model for health systems seeking to balance clinical quality, patient engagement, and financial sustainability in a value-based care environment.
Future campaigns will build on these results by: