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Improve Your HEDIS Measures by Closing Patient Care Gaps

Improve Your HEDIS Measures by Closing Patient Care Gaps

Improve Your HEDIS Measures by Closing Patient Care Gaps

Improving performance on HEDIS measures is a vital objective for any healthcare practice. These measures play a significant role in determining reimbursements and reflect the quality of patient care provided. One effective way to boost these scores is by closing patient care gaps.

HealthHelper focuses on the closure of care gaps to enhance HEDIS scores. Our approach combines advanced technology with personalized patient care coordination, ensuring that healthcare providers can efficiently identify and address gaps in patient care… without creating extra work for practice staff.

Understanding the Impact of Care Gaps and Closing Patient Care Gaps

Care gaps represent missed opportunities in preventive care, chronic disease management, or health screenings. These care gaps can lead to deteriorating patient health and increased costs in the long run. By identifying and addressing these gaps, practices not only improve patient outcomes but also demonstrate adherence to quality standards, which are crucial for performing well on HEDIS metrics.

HealthHelper’s Strategy for Closing Patient Care Gaps

Our solution involves a comprehensive 5 key approach:

Data-Driven Identification: We leverage data analytics to identify care gaps within the patient population. This includes utilizing EHR data, population health tool reports (e.g. Arcadia, Epic Healthy Planet, DignifiHealth, etc.), and predictive modeling to target areas that need attention.

Patient Outreach and Engagement: We understand that patient engagement is key. Our methods involve personalized communication and scheduling strategies that are tailored to each patient’s preferences, increasing the likelihood of them completing necessary treatments or screenings.

Continuous Learning and Adaptation: We analyze outcomes and refine our strategies based on data, ensuring that our methods are always aligned with the best practices and most effective approaches.

Collaborative Care Coordination: Working closely with healthcare providers, we ensure seamless integration of our strategies into existing workflows, emphasizing the importance of a team-based approach in healthcare.

Case Study: Improving HEDIS Measures by 10% - 30% with HealthHelper

HealthHelper recently helped a primary care group improve their HEDIS Measures by 10% - 30%. More importantly, the improvements in HEDIS quality metrics were significant and included both process and outcome measures. The practice experienced the following improvements from partnering with HealthHelper:

  • Breast cancer screening rates increased from 72 to 82 percent

  • Blood pressure control (<140/90 mm Hg) rates rose from 61 to 81 percent

  • Diabetic blood pressure control (<140/90 mm Hg) rates improved from 69 to 85 percent

  • A1C control (< 9%) improved from 66 to 79 percent

  • Attributed patients with visits increased from 64 to 72 percent

The Benefits of Partnering with HealthHelper

By choosing HealthHelper, practices can expect:

  • Improved HEDIS scores due to effective care gap closure.

  • Enhanced patient outcomes and satisfaction.

  • Streamlined administrative processes, freeing up resources for direct patient care.

  • An increase in overall healthcare quality and efficiency.

  • Participation in shared savings due to better spend reduction and quality performance.

Improving HEDIS scores through the closure of care gaps is a strategic approach that benefits both healthcare providers and patients. HealthHelper’s dedicated team, innovative technology, and patient-centered approach make it an ideal partner for practices aiming to enhance their healthcare delivery and achieve better outcomes.

Ready to Improve Your HEDIS Scores and Elevate Your Practice?

Connect with HealthHelper to learn more about our strategies for closing care gaps and improving HEDIS scores. Let’s work together towards a healthier future.

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What Is the Rural Health Transformation Program? An Overview for FQHCs

Rural and community-based providers have spent years managing the same structural problems: too few clinicians, aging infrastructure, patients who travel long distances for basic care, and razor-thin margins that leave no room for error. The Rural Health Transformation Program (RHTP) was created to help states address these problems by transforming rural healthcare delivery.

What Is RHTP? 

RHTP is a federal initiative, authorized through the One Big Beautiful Bill Act, that directs $50 billion in funding to states over five years (FY2026 through FY2030) to redesign and strengthen rural healthcare delivery. The Centers for Medicare & Medicaid Services (CMS) administers the program, but each state designs and submits its own transformation plan describing how it will use the money to improve access, provider sustainability, and care quality for rural populations.

How the Funding Works 

Funding is distributed in two ways: half is split evenly among approved states, and half is awarded competitively based on factors like degree of rurality, existing state policy support, and the ambition and quality of the proposed plan. States are expected to meet implementation milestones, report outcomes, and demonstrate progress throughout the five-year program. CMS retains oversight and may reduce or withhold funding if program requirements are not met.

Where the Money Tends to Go 

Because states retain flexibility in how they structure their programs, priorities vary, but a common set of themes shows up across almost every plan:

  • Stabilizing rural hospitals and clinics

  • Expanding access to primary and behavioral health care

  • Building the rural healthcare workforce

  • Improving chronic disease management and prevention

  • Modernizing technology, data, and care coordination infrastructure

  • Developing innovative payment models and value-based care

Why It Matters for FQHCs 

FQHCs are expected to play an important role in many state transformation plans. That matters, because FQHCs already carry much of the burden of rural primary care, chronic disease management, and care coordination, often with fewer resources than hospitals and health systems have.

Frequently Asked Questions

Who can apply for or participate in RHTP funding? 

Organizations that commonly participate in state RHTP initiatives include FQHCs, rural health clinics, hospitals, independent physician practices, behavioral health providers, public health agencies, and multi-organization partnerships.

Is RHTP funding only for hospitals? 

No. While hospital stabilization is a major focus, plans routinely include clinics, community health centers, workforce programs, and technology initiatives that extend well beyond inpatient settings.

Does technology count as a fundable investment? 

Yes. Technology investments are an important component of many state plans, particularly when they improve access, care coordination, digital health capabilities, operational efficiency, cybersecurity, or measurable health outcomes.

How long does the funding last? 

The program runs through fiscal year 2030, but individual state awards and provider-level funding are typically structured in multi-year, performance-based cycles.

How should FQHCs prepare today?

Although providers do not apply directly to CMS, FQHCs can position themselves by:

  • engaging with their state’s RHTP planning efforts;

  • identifying projects aligned with state priorities;

  • preparing measurable outcomes;

  • evaluating technologies that improve access, care coordination, workforce efficiency, and operational sustainability.

HealthHelper's AI-powered modules, including Call Helper, Visit Helper, Care Gap Helper, Transitions Helper, and Referral Helper, were built around these same fundable priorities. If your FQHC is building an RHTP strategy, a good next step is understanding how each priority area connects to deployable technology you can implement now.

Care New England and Integra Achieve Remarkable Improvements with AI-Powered Care Gap Closure Services from HealthHelper

Care New England and Integra Community Care Network (Integra) embarked on a transformative partnership with HealthHelper, aiming to address care gaps and enhance population health management. In just the first year of the HealthHelper partnership, this collaboration has led to significant advancements in patient retention and quality metrics, underscoring the impact of innovative healthcare solutions.

Achieving Notable Increases in Preventive Screenings and Quality Metrics

Through the integration of HealthHelper’s technology-enabled care gap closure services, Care New England reported substantial improvements in preventive care screenings:

  • Breast Cancer Screenings: 13% increase

  • Colorectal Cancer Screenings: 16% increase

  • Hypertension Screenings: 10% increase

  • Diabetic Eye Exams: 61% increase

  • Diabetic HbA1c Screenings: 29% increase

These enhancements reflect a concerted effort to close care gaps and promote early detection, pivotal components of effective population health management.

Strengthening Patient Retention and Care Coordination

A cornerstone of the partnership’s success is the impressive 88% in-network retention rate for screening mammograms. By ensuring patients receive coordinated care within the Care New England system, the collaboration has fortified patient trust and continuity of care. This strong care coordination helps ensure that patients receive their follow up care while also improving the financial standing of an important healthcare provider to the Rhode Island community.

Financial Impact and Return on Investment

The partnership has also yielded significant financial benefits:

  • Appointments Scheduled: 5,245 across the care continuum in the first year

  • Return on Investment: 3.4x

These outcomes highlight the dual advantage of enhancing patient care while achieving financial sustainability.

Seamless Epic Integration and Provider Workflows

Implemented in under two months, HealthHelper’s solution seamlessly integrated with Care New England’s Epic platform. This swift deployment alleviated administrative burdens, allowing providers to focus on delivering exceptional patient care. One team member remarked, “This is the easiest implementation project I’ve ever had!”

Leadership Endorsement: A Model for Scalable Success

Dr. Ana Tuya-Fulton, President and Chief Operating Officer of Integra and Chief Population Health Officer of Care New England, emphasized the strategic value of the partnership:

“Our partnership with HealthHelper has delivered measurable value for both our health system and our ACO. Their AI-powered Care Gap Closure services have improved performance, driven results, and seamlessly integrated into our workflows.”

Better Population Health with AI-Powered Care Coordination and Care Gap Closure Services

By combining technology-driven automation with high-touch patient engagement, HealthHelper is transforming how healthcare organizations identify, engage, and close care gaps at scale.

To learn more about how HealthHelper’s AI-powered Care Gap Closure services can support your organization, contact Jake Kahane at jake@healthhelper.co. To read more about the partnership between HealthHelper, Care New England, and Integra, check out this post by Care New England.

AI & Automation in Care Gap Closure and Practice Workflows – A Q&A with Jake Kahane, Co-Founder of HealthHelper

At HealthHelper, we believe that healthcare providers should spend their time delivering care—not chasing administrative tasks, managing fragmented workflows, or struggling to keep up with complex payer contracts. Our mission is simple: to take the work off providers’ plates so they can focus on their patients.

To dive deeper into HealthHelper’s journey, the challenges we’re solving, and what’s ahead, I sat down with Jake Kahane, Co-Founder & Chief Product Officer. We talked about what inspired him to start HealthHelper, the role AI plays in scaling care coordination, and his vision for the future of provider workflows.

From automating care gap closure to orchestrating complex workflows across healthcare networks, HealthHelper has built the infrastructure that allows providers to do more with less. Here’s what Jake had to say about how we got here—and where we’re headed next.

1. What inspired you to start HealthHelper?

The idea for HealthHelper really started with a simple observation: In population health, there’s no shortage of data—but providers struggle to turn that data into action. Health systems and medical groups have dashboards, reports, and lists of patients who need care, but actually operationalizing interventions—getting patients scheduled, closing care gaps, and ensuring follow-through—was a major challenge.

Over the years, I have learned a lot about patient engagement, care navigation, and what actually works to activate patients in their healthcare. It became clear that the place where this mattered most was primary care and preventive medicine—where the right intervention at the right time can prevent complications and improve long-term outcomes.

I wasn’t sure we were going to start a business, but I’ve always subscribed to the belief that when you have an idea, you just keep taking small steps forward and reassess along the way. The more we dug into the concept, the clearer it became that primary care providers were drowning in work. And when we started talking to them, practice managers, and staff, their reaction was the same: this would be a huge help.

That’s what keeps driving us today. We continue to hear from our clients that we’re making a real difference—offloading administrative burden, improving patient engagement, and ultimately helping practices succeed in both value-based and fee-for-service care.

2. What’s the biggest problem HealthHelper is solving today?

The biggest challenge we’re solving is simple: helping practices get more done with limited resources. Whether it’s a high-performing practice trying to scale or a group struggling to improve quality scores, the core issue remains the same—there’s too much work and not enough time or staff to handle it all effectively and efficiently.

We hear this all the time: “We’re doing fine now, but as we grow, we know this isn’t a scalable approach.” Even top-performing practices run into this. They’re doing well, but everything still feels manual, fragmented, and inefficient—and they know they can’t just keep working harder forever. And with constantly changing rules, payer demands, and operational complexities, it’s impossible to keep up without burning out.

The reality is, health systems, FQHCs, and medical groups know they need to close care gaps, improve coding accuracy, and meet quality targets—but they simply don’t have the bandwidth to do it efficiently. Staff are stretched thin, payer contracts keep evolving, and existing technology isn’t built to fit seamlessly into their workflows.

To make things even more challenging, hiring more people isn’t always the answer. Human capital is expensive, and many organizations can’t afford to throw money at the problem just to end up right back where they started. And when staff leave, it creates an even worse situation—disrupting workflows and setting them further back.

That’s where we come in. HealthHelper eliminates these barriers. We bring the right mix of technology, automation, and people to help practices actually get this work done—without adding to their burden.

From a product perspective, we’ve built a reliable, future-proof solution that not only helps practices scale—but also protects them when they need to contract. Whether they’re expanding or facing staffing shortages, they can rely on HealthHelper to provide stability, efficiency, and sustained performance—no matter what comes next.

3. HealthHelper is expanding its capabilities beyond closing care gaps. What’s next?

We’ve got some big product enhancements coming this year that we’re really excited about. I can’t share all the details just yet, but what I can say is that our clients keep asking us the same question: ‘What other workflows can HealthHelper help us scale?’

The reality is, healthcare has no shortage of inefficiencies and operational challenges. But solving them isn’t just about building technology—it’s about earning the trust of provider organizations to take these problems off their plate. That’s exactly what we’re doing.

Moving forward, HealthHelper will orchestrate and augment more of their workflows. We’ll be rolling out new solutions that allow practices and networks to quickly spin up tech-enabled workflows that scale, orchestrate, and hardwire best practices for specific patient populations. But this isn’t just technology, this includes the nimble service augmentation that actually gets the work done.

One of the biggest pain points we’re tackling is the constant changes in and impressive complexity of having to deal with a multitude of payer contracts. Every time a contract changes, practices aren’t in a position to completely overhaul their workflows for that payer’s patients. But with HealthHelper, they don’t have to. We combine technology and coordination resources to make those adjustments seamless.

Instead of spending weeks on planning, staffing, and change management, practices and networks can turn to HealthHelper to activate high-value workflows that drive performance improvements—without having to change their own workflow, without having to worry about tech integrations, and without adding more administrative burden. We orchestrate the workflow…and we execute the work.

4. What role do AI and automation play in HealthHelper’s future?

It’s an exciting time to be in care navigation—moreso than ever before, AI is allowing us to do more with fewer resources. But let’s be clear: AI isn’t here to replace providers or care teams—it’s here to amplify their impact.

At HealthHelper, we’re AI-enabling our care coordinators so that most of the patient engagement and care coordination can run on autopilot, while our team steps in when human judgment, creativity, and problem-solving are needed. Many patients want to know that there is a human there to help. HealthHelper clients learn quickly that in fact there are so many gaps and inefficiencies in healthcare that still require a real person to connect the dots, and that’s where the AI-plus-human approach becomes so powerful.

That’s also why we’re skeptical of companies claiming AI can do it all. Healthcare is complex. Data is messy. Systems don’t always talk to each other. We’ve seen firsthand that you still need people in the loop to ensure nothing falls through the cracks. That’s why our focus is on AI working alongside humans both to scale adoption of coordinator best practices and to actually take work off our clients’  plates—end to end.

5. Where do you see HealthHelper in five years?

When I think about where HealthHelper will be in five years, I think about the brand we’re building. Right now, we’re known as a trusted partner for primary care providers—an extension of their team that actually helps them get work done. That trust is everything, and it’s what sets us apart.

Five years from now, HealthHelper will still be that trusted partner—but our impact will go far beyond care gap closure. We’ll be known for orchestrating and augmenting all types of provider workflows—helping practices and health systems run more efficiently, scale operations, and do more with less.

We’ve already proven that we can seamlessly integrate into primary care teams and take work off their plates. That foundation gives us the ability to expand—taking on more administrative and operational burdens so that providers can focus on patient care. And as we grow, we’ll continue leveraging AI and automation to make our solutions even more effective and efficient.

Ultimately, I see HealthHelper becoming a critical infrastructure piece for primary care, health systems, and the networks that support them. We’ll be the go-to partner for healthcare organizations that want to scale highly effective provider workflows—powered by smart automation and deep healthcare expertise.

That’s where we’re headed, and I couldn’t be more excited about what’s next.

HealthHelper: Born From the Frontlines of Primary Care

I didn’t start my career thinking I’d build a company. I became a primary care physician to help people—to care for patients and make a real difference in my community. My days were full but meaningful—managing medications, seeing patients back-to-back, addressing urgent issues, and keeping the practice running smoothly.

But over time, something shifted.

Increasingly, my clinical responsibilities weren’t the only thing demanding my attention. I was handed chase lists—long lists of tasks tied to closing care gaps and meeting payer performance metrics. These lists weren’t just overwhelming—they were riddled with inaccuracies and existed completely outside of my primary systems and workflows. I’d review the lists, often feeling frustrated. I knew my team and I had already discussed many of these preventive screenings and follow-ups with our patients. So why were they still appearing?

Oh yeah…patients have lives outside of my clinic, they get busy and forget. So what am I supposed to do about this? I didn’t have the staff, tools, or time to systematically tackle this extra workload.

Some of my colleagues were using ad-hoc methods. One provider handed out bright pink slips to patients reminding them to schedule their mammograms, while others made verbal reminders to “come back in six months” for a diabetes follow-up. My team and I took to making phone calls when we had a spare moment (which were few and far between). It was inconsistent, inefficient, and often ineffective.

The challenge wasn’t just closing care gaps. It was that meeting these payer requirements directly impacted our ability to succeed as a practice—yet no one had a scalable, effective way to manage it.

I knew there had to be a better way.

The Turning Point

That’s why I founded HealthHelper.

I wanted to create a solution that took the work off providers’ plates—so they could focus on their patients, not on the endless administrative tasks required to perform well on payer contracts. I wanted to offer something that gave providers relief—the confidence that their practice could meet performance goals without compromising patient care. AND, it had to make it easy for patients, otherwise, it wouldn’t move the needle.

HealthHelper was built to solve exactly this problem.

We take on the work providers don’t have time for:

  • We close care gaps by identifying patients overdue for preventive services and actually scheduling their care for them.

  • We help you perform better on payer contracts by managing the operational lift of care coordination and patient engagement.

  • We become your performance partner, ensuring you meet key performance measures while reducing staff burden.

The Impact We Strive For

Today, HealthHelper works with providers and health systems to make sure no care gap goes unaddressed. Our team handles the administrative complexity, allowing care teams to focus on what they do best.

We’re not just a technology platform or service; we’re a true partner in performance.

To my fellow providers: I see you. I know how hard you’re working. HealthHelper exists to ensure you can keep doing what you love—caring for patients—while we take care of the rest.

Let’s make healthcare better, together.