If your patient in the Primary Care, Federally Qualified Health Centers (FQHC), or Behavioral Health specialty, synchronized with Population Health System (PHS) has clinical gaps in care, you can assess and resolve the Hierarchical Condition Categories (HCC) diagnoses in the Patient Insights section in Patient Chart. You can provide the patient the necessary care and help your practice obtain reimbursement depending on the patient's insurance. The gaps count of upcoming and overdue items, and the Adjusted Clinical Groups (ACG) risk score for the patient appear on the header.
You can select the
Patient Insights section to view the following details:
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Risk score overview
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In Risk Score, the ACG, Atherosclerotic Cardiovascular Disease (ASCVD), and HCC scores appear for patients having clinic visits in the last twelve months. In cases where patients lack claims data, risk scores are calculated using active problems in the problem list.
To view the risk score definitions and details, you can select 
.
indicates a high-risk score.
- HCC Opportunities
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To provide the best possible care to the patient and resolve the HCC diagnoses, you can add diagnoses to the assessment in the current encounter, and then select Resolve to move the diagnosis to the resolved status. You can also add comments while resolving the HCC diagnoses. The assessments are the problem (ICD-10/HCC code) that you must add to the patient list. If the assessment has any drug interaction alerts, a message appears. You can select Continue or Acknowledge to add the diagnoses to the assessment, and then select Resolve to move the status. When you resolve an HCC diagnosis, NextGen® Mobile adds the diagnosis code to the ICD list.
- Gaps in Care
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The details appear for the following gaps:
- Completed gaps
- Upcoming gaps in care
- Gaps that are past due
- Failed gaps
Note: If your patient in the Primary Care, Federally Qualified Health Centers (FQHC), or Behavioral Health specialty, synchronized with Population Health System (PHS) has clinical gaps in care with high-risk scores, the
indicator appears in the
Schedules view.
