Preventive care gaps are a major challenge for health plans, especially among disengaged or underserved members. These gaps often persist—not because members are non-compliant, but because clinical data is outdated or incomplete. The result? Missed care needs, inefficient outreach and unnecessary spending.

This session explores how one national Medicare program is changing preventive care delivery by combining real-time clinical data aggregation with in-home care. By integrating claims data, pharmacy records and health information exchanges, the program created a comprehensive view of each member to help care teams avoid false positives and uncover overlooked gaps.

Now active in more than 20 states and expanding in 2025, the model is delivering clear results. Health plans have used it to close inaccurate gaps, identify new needs and deliver in-home visits to high-risk members, addressing multiple HEDIS® measures in one encounter at a lower cost than traditional nurse visits. The model also improves data sharing. 

For plans aiming to cut member abrasion, raise quality scores or scale social care, this session is a practical look at how data-driven, in-home care can deliver smarter, more equitable results.

Session Takeaways

• Discover how real-time clinical data aggregation helps reduce false positives and improve HEDIS performance.
• Understand how integrating data with in-home care supports more targeted, cost-effective outreach.
• Explore how this model enables risk stratification, identifies unmet needs and improves care coordination.