> ## 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.

# Population Health & Care Gap Management — User Guide

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

**Spec:** [CL-35](../../specs/cl/specs/CL-35-population-health-care-gap-management.md)
**Audience:** Care managers, clinicians, supervisors, quality team
**Last Updated:** 2026-05-11

***

## 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.

***

## Navigation

All Population Health pages live under **Clinical → Population Health**.

| Page                 | Path                                     | Permission                              |
| -------------------- | ---------------------------------------- | --------------------------------------- |
| Care Gap Work List   | `/cl/population-health/care-gaps`        | `cl.care-gaps.view`                     |
| Clinician Panel      | `/cl/population-health/my-panel`         | `cl.care-gaps.view`                     |
| Supervisor Panels    | `/cl/population-health/supervisor`       | `cl.care-gaps.view` (+ supervisor role) |
| Population Dashboard | `/cl/population-health/dashboard`        | `cl.population-dashboard.view`          |
| Quality Measures     | `/cl/population-health/quality-measures` | `cl.quality-measures.view`              |

***

## 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.

### Filtering

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

### 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.

***

## 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.

***

## 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.

***

## 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).

***

## 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.

### 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.

***

## Permissions Summary

| Permission                     | What you can do                   |
| ------------------------------ | --------------------------------- |
| `cl.care-gaps.view`            | View work list & panels           |
| `cl.care-gaps.close`           | Close gaps manually with a reason |
| `cl.risk-stratifications.view` | View risk tiers and components    |
| `cl.population-dashboard.view` | View aggregate dashboards         |
| `cl.quality-measures.view`     | View HEDIS / MA STARS results     |
| `cl.quality-measures.export`   | Export VBP CSV                    |

***

## Need help?

* Spec reference: [CL-35](../../specs/cl/specs/CL-35-population-health-care-gap-management.md)
* Admin guide: [Population Health Admin Guide](./population-health-admin-guide.md)
* Cross-core integrations: [CL-35 Integration Doc](../architecture/integrations/population-health-integration.md)