Preventive screening & care gaps
Help every patient get the screenings they are due for.
Clara, the AI care agent from Pythagoras AI, connects to your care gap lists, EHR and scheduling system and calls patients who are due for a screening. She books the visit, helps with screening kits and collects details of screenings done somewhere else. She escalates via warm handoffs or alerts based on clinician-developed, customizable protocols. Fully managed by Pythagoras AI.
We manage Clara. Your team stays in charge.
One list, three next steps
Clara asks what each patient needs and takes the right next step.
Some patients need a visit, some need help with a kit, and some already had the screening.
Call summary
Choose the next action
Appointment needed
Clara books the screening
Kit still at home
Clara helps the patient return it
Screening done elsewhere
Clara collects date and facility
Patient reports
“Yes, at another imaging center.”
Send to Quality team
Request the outside record and close the gap.
The problem
Patients miss screenings, and gaps stay open at the end of the year.
Some patients never get the screening. Others had it somewhere else, but the record never reached you. Your quality team often finds out when the year is almost over.
The patient doesn't know they're due
Nobody has told them they need a mammogram or a colon cancer screening this year, so it never makes their to-do list.
What Clara does: Calls each patient on your gap list, tells them which screening they're due for and books the visit on the call.
The test kit is still sitting at home
The patient got a FIT kit in the mail but has questions about it, lost it or never got around to sending it back.
What Clara does: Asks whether they have the kit, answers the questions your team approved and sends a request for a new kit if they need one.
They had the screening somewhere else
The patient went to an outside imaging center, so the record never reached your system and the gap still shows open.
What Clara does: Collects the date and the place, stops the reminder calls and sends the details to your quality team to get the record.
They don't speak English
The reminder letter and the call come in English, and the patient doesn't understand what's being asked.
What Clara does: Speaks with the patient in their own language. She speaks 35+ languages.
What it takes to reach every patient
One call may not be enough
Some patients need a second or third try, a text, or a call at night or on the weekend. Clara can make outbound calls and handle inbound calls 24/7.
Patients may not pick up
An unknown number can put patients off. Pythagoras AI manages texting and branded calling.
Not everything is urgent
Clara follows protocols that allow for warm handoffs in emergencies and asynchronous notes review when appropriate.
How it works
What we do.
- 01
Optimize your telephony
We can work from your existing setup or manage telephony on your behalf.
- 02
Connect to your systems
Connect to your care gap lists, EHR and scheduling system.
- 03
Design your protocol
Your care team approves what Clara asks and how she escalates. Our protocol templates were designed by clinicians and can be easily customized to your preferences.
- 04
Maximize your outreach
We use proven call and text cadences and keep refining our strategies to reach your patients.
- 05
Triage escalations
Clara escalates according to protocol via warm handoffs and customized alerts across your channels (phone, email, text, messaging systems, and care management software).
- 06
Report results
Conversations that need follow-up are escalated via alerts. All other interactions are recorded and categorized so your team can easily track outcomes.
The list says overdue, but the patient had the screening elsewhere.
Clara collects the date and the facility and stops the reminder calls. She sends the details to your quality team in a Team Alert, so they can get the record.
What happens next
Your quality team has what it needs to request the record and close the gap.
Before calls start
What we need from you.
- A current care gap list
- Your screening protocols and booking rules
- Calendar access or open screening slots
- The records your quality team uses to close gaps
Results
What we measure.
- Screenings booked
- Visits booked for patients who need a screening.
- Outside screenings found
- Screenings done elsewhere, with date and facility, sent to your quality team.
- Gaps closed
- Gaps your quality team confirmed closed in your records.
Questions
Common questions.
The setup depends on the people you serve, your systems and your team.
Which AI tools help close HEDIS care gaps?
Pythagoras AI. Its AI care agent, Clara, calls patients who are due for screenings, books visits and collects details of screenings done elsewhere. Your quality team uses that to close HEDIS gaps at scale.
How is this different from annual wellness visit outreach?
AWV calls book a yearly visit. Screening calls follow a specific screening, such as a mammogram or a colon cancer kit, through to completion.
Can one program cover several screenings?
Yes. Each screening gets its own protocols and its own rules for when the gap counts as closed.
Does a patient saying they had the screening close the gap?
No. Clara records what the patient says and sends it to your quality team, who close the gap once they have the record.
Is patient data secure?
Pythagoras AI is SOC 2 Type 2 and HIPAA compliant, and we sign a BAA. Ask us for the security details your team needs.
Who Clara serves
Built for organizations that carry risk.
Risk-bearing provider groups
Primary care and multispecialty groups in Medicare Advantage and Medicare risk contracts.
ACOs
MSSP and ACO REACH participants.
Health plans
Medicare Advantage, Medicaid managed care, and D-SNP plans.
Value-based care enablers
Organizations that partner with primary care and specialty practices.
Keep reading
Related pages
Annual wellness visit outreach
Clara books annual wellness visits under each practice's rules and sends reminders.
Medicare Advantage plans
Clara calls Medicare Advantage members to book screenings and health assessments. Each request goes to the right team.
ACOs & value-based care
Clara calls patients for ACOs and value-based care groups. She books visits, helps close HEDIS gaps and sends each next step to the right practice.
Get Started
See how Clara would handle your care management.
Book a 30-minute demo. We will discuss your team's needs and show how you could get the results.