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Work care gaps and outreach

Draft — 2026-09-27

Drafted from the screen's code on main (karemanager fddd13c). Not yet reviewed against a live session. Roles listed are the defaults the app's role matrix (@collabkare/ability 0.13.0) gives this screen's route; your organization's role overrides can change them.

One live worklist for three kinds of gap: Care Gap Closure cases raised on Quality Measures, Wellness visit outreach, and HCC recapture items from the analytics registry.

Before you start​

  • You need the Care Coordinator, Care Navigator, Nurse Care Manager, or Pop Health Manager role.
  • In the left menu, go to Members → Care Gaps & Outreach.

Steps​

  1. Read the KPI strip (open, closed and high-priority counts per type). Click a tile to filter by it.
  2. Narrow the list with the type, status and priority filters. New review opens a case by hand.
  3. Click a case row, for example the patient name, to open it.
  4. Use the action bar: Assign, Attach document, Create referral, Log outreach attempt. Care Gap Closure cases add Escalate; Wellness visit and HCC recapture cases add Send query. Schedule visit (Care Gap Closure and Wellness visit only) opens a form with a Book in karePractice link.
  5. On a Care Gap Closure case, record the closure on the Determination tab with its attestation.
  6. Under Move to, advance the status, for example to In outreach or Closed. Click Back to worklist when done.

Tips / Troubleshooting​

  • Each type is gated by its own permission: case_review_care_gap, case_review_mwv_outreach, case_review_hcc_recapture. A type your role doesn't hold is left out of the list, filters and New review.
  • Book in karePractice books nothing itself; submit the form once the practice confirms.
  • Coders who only work recapture can use CDI & Risk Adjustment → HCC Recapture Queue.