Care Gaps

by Bamboo Health  · Based in United States → — Real-Time Care Gap Identification Solution
Family Medicine Hospital Medicine Internal Medicine
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Overview

Care Gaps by Bamboo Health is a Real-Time Care Gap Identification Solution designed to help providers and payers quickly find and close open gaps in care. It delivers immediate notifications and detailed insights, enabling better outcomes and improved quality measures.

The solution addresses information barriers and misaligned workflows between providers and payers that make it difficult to identify and reconcile high-impact moments for patients, such as transitions of care from an inpatient setting and prompt follow-up care after an emergency department visit for patients with chronic conditions.

Leveraging Bamboo Health’s robust national admission, discharge and transfer (ADT) network, Care Gaps actively surfaces these gaps in real time and within provider workflows. This fosters better care coordination, enhances patient care outcomes, increases cost savings, and improves quality performance with programs such as CMS Star Ratings and HEDIS.

Reviewed by Pouyan Golshani, MD — Interventional Radiologist

Key Features

  • Real-Time Care Gap Identification
  • Immediate Notifications
  • Detailed Insights
  • Leverages National ADT Network
  • Surfaces gaps within provider workflows
  • Improved Patient Outcomes
  • Optimized Care Collaboration
  • Meets & Exceeds Quality Measures (CMS Star Ratings, HEDIS)
  • Fluid and quick data transfer
  • Real-Time Care Intelligenceu2122

Use Cases

  • Quickly finding and closing open gaps in care
  • Delivering better patient outcomes
  • Improving quality measures (CMS Star Ratings, HEDIS)
  • Optimizing care collaboration between payers and providers
  • Reducing length of stay
  • Decreasing 30-day inpatient readmissions

What Physicians Need to Know

Patient Portal Integration
Features direct EHR integration, centralizing the solution within provider workflows, which can facilitate patient engagement through existing patient portals.
Chronic Disease Management
Focuses on identifying and closing care gaps for members with chronic conditions, including prompt follow-up care after emergency department visits, screenings, and adherence to evidence-based guidelines.
Medication Adherence Features
Identifies open care gaps related to medication checks and supports medication reconciliation during transitions of care.
Physician Tip

Physicians can leverage Bamboo Health's Care Gaps solution to receive real-time notifications and detailed insights into open care gaps for their patients, such as missed screenings, post-treatment follow-ups, and medication checks. This enables them to prioritize actions, streamline workflows, and make informed care decisions to quickly close gaps and improve patient outcomes and quality measures like HEDIS and Star Ratings. The direct EHR integration centralizes these insights within their existing workflow, reducing administrative burden and enhancing care coordination.

Bamboo Health's Care Gaps solution features direct EHR integration, centralizing the solution within provider workflows. It leverages Bamboo Health's Smart Signalsu2122 network and national admission, discharge, and transfer (ADT) network to surface real-time care gap opportunities. This integration allows for fluid data transfer between health plans and providers, supporting better care coordination and quality performance improvements. Other Bamboo Health solutions, such as Pingsu2122 and Rising Risk, also integrate into existing clinical workflows to provide real-time patient event alerts and risk stratification.

Details

Category Patient Engagement & Education
Pricing Unknown
DeploymentCloud-based
Compliance
BAA Available Yes AI-estimated
HIPAA Compliant Yes AI-estimated
FDA Status Unknown AI-estimated
Integrations
EHR Not specified
Specialties Family Medicine, Hospital Medicine, Internal Medicine

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Clinical Value
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Press & Coverage

PR Newswire
Delaware Documents 45% Increase in Behavioral Health Treatment Referrals in First Year of Bamboo Health's OpenBeds Referral Network
Delaware's digital network, built on Bamboo Health's OpenBeds platform, saw a 45% increase in behavioral health treatment referral requests in its first year, highlighting existing care gaps in the behavioral health system. The platform provides immediate visibility into resource availability, helping to connect clients with appropriate substance use and mental health services faster.
2021-12
Imaging Technology News
5 Technologies to Help Overcome Healthcare Disparities in the Next Decade
This article discusses how technologies like AI, 5G, telehealth, point-of-care testing, and smartphones can reduce healthcare disparities and address care gaps. AI, in particular, is gaining regulatory approval and being integrated into healthcare to improve workflow, speed diagnoses, and make medical devices more intelligent.
2021-07
Frontiers in Medicine
Evaluating the Effectiveness of Medicalu2013Dental Integration to Close Preventive and Disease Management Care Gaps
A study found that patients with preventive or disease management care gaps who received dental care in a Medical-Dental Integration (MDI) clinic had higher odds of closing these gaps. MDI may be an effective model for facilitating the delivery of preventive and disease management services, especially when patients are overdue for one type of service.
2021-07
Pharmaceutical Technology
Q&A: How AI-driven solutions are helping close care gaps in precision medicine adoption
This Q&A explores how AI and real-time data are becoming essential tools to close care gaps, improve adherence to clinical guidelines, and enhance precision medicine. AI can shorten the learning curve for new therapies by embedding critical information directly into the clinical workflow.
2025-07
Annals of Family Medicine
Impact of Epic Care Gaps on Hepatitis B Care Retention
A study examined the impact of an Epic EHR 'care gap' prompt designed to improve chronic hepatitis B (CHB) retention in care. The prompt, which alerted staff if a CHB patient had not received a hepatitis B DNA level in the prior 12 months, meaningfully improved retention in CHB care.
2026-06
PR Newswire
League Spring '26 Release: The New Frontier for Orchestrated AI Care Navigation and Care Gap Closure
League's Spring '26 Release introduces new AI-powered solutions, including a Care Gaps Agent Team, to move beyond passive analytics and proactively address barriers to care. These solutions aim to close the 'action gap' in healthcare by identifying predictive barriers and social determinants of health risks.
2026-03
Becker's Behavioral Health
Wider care gaps predicted as mental health parity rule faces rollback
Healthcare leaders are concerned that the federal government's decision to rewrite the 2024 Mental Health Parity and Addiction Equity Act Final Rule could weaken enforcement and widen disparities in behavioral healthcare. This rollback could exacerbate access challenges and increase administrative burdens for health systems.
2026-04
AHA News
SAMHSA advisory addresses ways to close care gaps in behavioral health service deserts
The Substance Abuse and Mental Health Services Administration (SAMHSA) released an advisory exploring innovative solutions to close care gaps in behavioral health service deserts. The advisory highlights that over 60% of rural Americans live in designated behavioral health shortage areas and suggests integrating community health workers and peer support specialists.
2026-03

Videos

Product demos, reviews, and walkthroughs for Care Gaps.

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Frequently Asked Questions

Effectively identifying care gaps involves leveraging EHR data tracking, claims data analysis, and risk stratification to pinpoint missed screenings or overdue care. Strategies include embedding real-time alerts during patient encounters, conducting between-visit outreach with automated reminders, and running problem-specific campaigns for particular care gaps.
Successful strategies for improving patient adherence include educating and engaging patients about their conditions and the importance of preventive care, maintaining consistent communication, and addressing social determinants of health (SDOH) like transportation or financial strain. Personalized communication, tailored to individual preferences and delivered through various channels, is also crucial for better engagement.
Beyond standard outreach, consider innovative approaches like implementing Chronic Care Management (CCM) programs for consistent, personalized communication and follow-up, or utilizing telehealth services to expand access to care, especially for remote patients. Technology-driven solutions, such as AI-powered platforms for multi-channel patient engagement and intelligent scheduling, can also streamline the process.
Investing in care gap closure programs can lead to increased revenue by billing for additional medically necessary services and improving performance in value-based care contracts like MIPS, which can lead to higher reimbursements. Annual Wellness Visits (AWVs) are a significant revenue-generating opportunity, often underutilized, and can be performed by non-physicians.
Primary barriers include patients' lack of awareness, limited understanding of risks and benefits, cost concerns, and access issues like transportation. Practices can overcome these by providing clear patient education, personalized communication, addressing SDOH, and building trust so patients understand the value of prevention.
Technology can streamline care gap management through EHR data tracking, claims analysis, and AI-driven risk stratification to identify high-risk patients. Automated systems can then facilitate multi-channel patient outreach (SMS, email, voice AI) and intelligent scheduling for appointments, significantly reducing staff burden and improving closure rates.

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Suggest an Edit → | Last Verified: 2026-04-26 | First Added: 2026-04-26
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