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Documentation Index

Fetch the complete documentation index at: https://docs.encoreos.io/llms.txt

Use this file to discover all available pages before exploring further.

Spec: CL-35 Audience: Care managers, clinicians, supervisors, quality team Last Updated: 2026-05-11

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Overview

Population Health gives care managers and clinicians proactive tools for managing their patient panel: identifying open care gaps, reviewing risk stratification, monitoring program-level outcomes, and tracking quality measure performance for AHCCCS VBP, NCQA HEDIS, and CMS MA STARS reporting.
All Population Health pages live under Clinical → Population Health.
PagePathPermission
Care Gap Work List/cl/population-health/care-gapscl.care-gaps.view
Clinician Panel/cl/population-health/my-panelcl.care-gaps.view
Supervisor Panels/cl/population-health/supervisorcl.care-gaps.view (+ supervisor role)
Population Dashboard/cl/population-health/dashboardcl.population-dashboard.view
Quality Measures/cl/population-health/quality-measurescl.quality-measures.view

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1. Care Gap Work List

The Work List shows all open care gaps assigned to your panel, sorted by severity (overdue first), then due date. Use this view to plan your outreach for the day.

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Filtering

  • Gap type — assessment overdue, follow-up not scheduled, screening due, etc.
  • Severity — overdue, due-soon, future.
  • Patient — quick filter by chart name.

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Closing a gap

  1. Click a gap row to open the patient chart in a side panel.
  2. Complete the required clinical action (assessment, follow-up scheduling, screening, etc.).
  3. The gap auto-closes when the underlying clinical event is recorded (e.g. assessment finalized, follow-up appointment booked).
  4. To override a gap manually (clinician judgment), select Close with reason and pick a closure reason. Manual closures are audit-logged.

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2. Clinician Panel

My Panel lists every patient currently assigned to you, with their risk tier (low / medium / high / critical) and open gap count. Click a row to drill into the patient chart. Risk tiers are computed nightly by the risk-stratification job from up to four components (CL-07 safety, CL-10 outcome, CL-22 metabolic, CL-21 MOUD). For patients without 42 CFR Part 2 consent, MOUD is excluded and weight is redistributed across the remaining components.

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3. Supervisor Panels

Supervisors see all clinicians in their team plus aggregate panel metrics: average risk score, open gaps per panel, gap closure rate, and outcome trends. Use this to balance caseloads and target coaching.

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4. Population Dashboard

Aggregate, organization-level dashboards covering:
  • Risk tier distribution
  • Care gap summary by type
  • Outcome trends (PHQ-9, GAD-7, etc.)
  • Disaggregation by site, program, payer, age band, primary diagnosis
Privacy note: All cells with fewer than 5 patients are suppressed and displayed as <5 (HIPAA Safe Harbor de-identification).

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5. Quality Measures

The Quality Measures page shows HEDIS and CMS MA STARS measure period results for the selected reporting year:
  • AMM — Antidepressant Medication Management (acute / continuation)
  • IET — Initiation & Engagement of SUD Treatment
  • FUH / FUM — Follow-up After Hospitalization / ED Visit (sourced from CL-29-EN-65)
Switch between HEDIS and MA STARS tabs at the top. Use the year selector to compare across reporting periods.

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VBP Export

Users with cl.quality-measures.export may export the VBP CSV for AHCCCS reporting. The CSV contains aggregate metrics only — never patient identifiers — and applies small-cell suppression.

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Permissions Summary

PermissionWhat you can do
cl.care-gaps.viewView work list & panels
cl.care-gaps.closeClose gaps manually with a reason
cl.risk-stratifications.viewView risk tiers and components
cl.population-dashboard.viewView aggregate dashboards
cl.quality-measures.viewView HEDIS / MA STARS results
cl.quality-measures.exportExport VBP CSV

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