Closing the care loop:
optimized population health
through data-driven preventive care

A use case on how blueBriX enables proactive, data-driven preventive care outreach and closes care gaps across populations

Enterprise Preventive Care Gap Closure

Systematically identify and close preventive care gaps across populations with repeatable, data-driven workflows.

Stronger quality and value-based performance

Improve performance on CMS, Stars, and HEDIS measures while protecting shared-savings and value-based revenue.

Operational efficiency with real-time visibility

Automate population health operations and gain real-time insight into outcomes, performance, and resource utilization.

blueBriX preventive care campaign engine: closing gaps at scale

Problem
Preventive care gaps are difficult to identify consistently

Preventive needs are often scattered across EHR modules, claims data, and external systems. As a result, care teams struggle to maintain an accurate, up-to-date view of which patients are due or overdue for screenings, immunizations, or wellness visits.

Solution
blueBriX cohort stratification & predictive analytics

blueBriX leverages Cohort Stratification & Predictive Analytics to aggregate clinical, claims, and demographic data into comprehensive risk-ranked populations. Care teams can segment patients who are due for colorectal screening, mammography, annual wellness visits, immunizations, or other preventive measures without manual querying. This enables targeted, measurable campaigns that drive meaningful improvements in preventive uptake.

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Problem
Outreach is manual, inconsistent, and hard to scale

Effective preventive care requires timely, personalized outreach, yet many practices rely on manual outreach, disparate reminders, or one-off notifications that fail to resonate or scale. Patients may be unaware of recommended services or unsure how to schedule them.

Solution
Build custom outreach campaigns and automate tasks

blueBriX empowers providers to create multi-channel preventive care campaigns using automated workflows. Messages can be tailored by cohort, language, risk profile, or clinical need, and deployed via text, email, phone, or patient portal. Reminders, education content, and scheduling prompts are all built into the campaign workflow, increasing patient responsiveness and adherence.

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Problem
Care teams lack visibility into campaign effectiveness

Clinicians and administrators often have limited visibility into which preventive campaigns are performing, who has responded, and where care gaps persist. This lack of insight makes it hard to optimize outreach and demonstrate outcomes.

Solution
Performance tracking with blueBriX population health dashboards

blueBriX’s Outcome Monitoring & Dashboards consolidate campaign results, completion rates, and engagement trends in real time. Providers can monitor progress against preventive care goals, measure impact on population health measures, and adjust strategies dynamically. Dashboards also support reporting for quality programs such as HEDIS and Star ratings by illuminating preventive gap closure performance.

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Problem
Reactive care models delay preventive interventions

Traditional care delivery often reacts to patient contacts rather than proactively preventing disease. Without scalable preventive campaigns, care teams are unable to anticipate needs or reduce avoidable complications before they escalate.

Solution
blueBriX predictive care pathways

blueBriX enables providers to embed Predictive Care Pathways within preventive care campaigns that guide follow-up actions, clinician interventions, and longitudinal tracking. These pathways connect risk detection to tailored care plans and automated follow-ups, helping providers close care gaps before they result in clinical deterioration or costly utilization.

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Problem
Preventive care efforts are disconnected from care workflows

Preventive outreach often exists outside the clinical workflow, resulting in missed follow-ups, unclear ownership, and limited integration with care coordination activities.

Solution
Care pathway activation with blueBriX care coordination workflows

blueBriX embeds preventive campaigns directly into Care Coordination Workflows, automatically generating tasks, follow-ups, and care pathways when patients respond or schedule services. This ensures preventive outreach translates into completed care—not just engagement.

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The impact

Investing in structured, scalable preventive care campaigns transforms population health performance and aligns clinical workflows with quality expectations.

Higher preventive service uptake

Risk stratification and targeted outreach drive measurable increases in screenings, immunizations, and wellness visit completion.

Improved quality & value performance

Enhanced preventive care performance strengthens quality program results, supports value-based contracts, and aligns with CMS and population health expectations.

Operational efficiency for care teams

Automated campaigns and real-time monitoring reduce manual workload, allowing care teams to focus on meaningful patient engagement and outcomes.

Patient centricity & engagement

Personalized, timely outreach keeps patients informed and empowered, improving satisfaction and trust in care delivery.

Conclusion

In a healthcare landscape where preventive care is a strategic priority, provider organizations must move beyond ad-hoc reminders and toward scalable, data-driven campaign management. blueBriX equips care teams with the tools to identify preventive care gaps, execute tailored outreach, measure engagement, and drive results. By embedding predictive analytics, automated outreach, and real-time dashboards into a unified care coordination platform, blueBriX helps providers close care gaps at scale, improve population health outcomes, and meet evolving policy expectations for preventive services.