Written by the Patientrig team — clinical informatics, care coordination, and healthcare data engineering. We write about what the research says, what we've seen in the field, and where the tooling still falls short.
The 90-day window after discharge is when most chronic patients lose contact with their care team. Here's what's driving that gap and how proactive outreach changes the trajectory.
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No-show rate is a lagging indicator — you already missed the intervention window. The signal that matters is when a patient's appointment sequence starts to break down, weeks before the no-show registers.
CHF patients respond to pharmacy alerts at a higher rate than phone calls. Younger T2D patients respond to SMS faster than either. Channel preference isn't a soft preference — it changes intervention success rates by condition.
Not all care gaps carry equal financial weight under VBC contracts. This breakdown shows which failures map most directly to penalty triggers.
Labs and vitals tell you what's wrong today. ADT events, Rx fill history, and appointment sequence tell you who's about to go silent.
30-day readmission rates for CHF are tracked obsessively. But the ACE inhibitor refill not picked up on day 18? Nobody knows until day 29.
The Monday-morning report-and-call routine isn't broken because coordinators are slow. It's broken because the queue isn't ranked and the outreach isn't automated. Here's what changes when it is.
Metformin non-adherence looks different at month 3 vs. month 18 post-diagnosis. Intervention timing and channel choice should match the pattern.
Automated SMS to patients involves PHI. Here's how to evaluate whether a vendor has actually thought through the compliance requirements.
EHR reports tell you who's overdue. They don't tell you who's about to become overdue. That shift changes everything.
Patients who miss their pulmonology follow-up in October have roughly twice the winter admission rate of those who don't. The pattern is consistent across five years of claims data — and Sept–Oct is when the intervention needs to happen, not December.
HEDIS BP control measures are binary: controlled or not. But the care gap that matters most is the 60-day window where a patient stops reporting readings entirely.
VBC penalty exposure per unreached attributed patient is calculable. If you know your disease mix, your attributed panel size, and your current gap closure rate, the ROI math on proactive outreach is straightforward. Here's how to run it.