To consolidate patient outreach for care gaps, keep one record per patient that lists every open item: adherence, quality gaps, wellness visits. Rank those items, cover them in one conversation, and apply the same consent and opt-out status across every team. One call replaces three, and the patient hears from you once.
Takeaways
Siloed lists mean repeat calls
Adherence, quality and wellness teams often call the same patient in the same week.
One record per patient fixes it
Every open item lives in one place before anyone picks up the phone.
Prioritize inside the call
Urgent items first, then the rest, without turning it into a 20-minute survey.
One opt-out, everywhere
If a patient says stop to one team, every team stops.
Three teams, one patient, three calls
Picture a typical week. On Tuesday, the pharmacy or adherence team calls Ms. Jones about her overdue statin refill. On Wednesday, the quality team calls to schedule her mammogram. On Friday, the wellness team calls about her annual wellness visit.
Each team did its job. Each call may even have gone well. But Ms. Jones heard from the same practice three times in four days, from three different people, about three separate things. By the third call, she may stop answering.
This happens because each team works from its own list. The adherence list comes from the payer's pharmacy file. The quality list comes from the care gap report. The wellness list comes from an EHR report of patients due for an annual wellness visit. Nobody joins them.
Why it costs more than it looks
Repeat calls have three costs.
Patient fatigue. Every unwanted call makes the next one less likely to be answered. Patients who feel hounded opt out, and an opt-out from one team should stop every team.
Wasted staff time. Three people each find the number, dial, wait, explain who they are and log the result. Most of that work is the same work, done three times.
Missed openings. When the adherence caller has Ms. Jones on the line, they don't know she's due for a mammogram. The one moment you had her attention is gone.
There's a compliance angle too. Under FCC rules, exempt healthcare calls and texts to a wireless number are limited to one per day and three per week. Separate teams calling from separate lists can hit that limit without knowing it.
The fix: one patient record with every open item
The answer is to flip the unit of work from the campaign to the patient. Before anyone calls, ask: for this patient, what's open?
| Feature | Campaign by campaign | One patient, one conversation |
|---|---|---|
| Source lists | Each team keeps its own | Joined into one record per patient |
| Who calls | Up to three teams, separately | One call covers every open item |
| What the caller knows | Only their own item | Every open item, ranked |
| Opt-out | Tracked per team, if at all | One status, applied everywhere |
| Weekly contact limits | Hard to track across teams | Counted per patient |
| Patient experience | Three calls in a week | One conversation |
In an AI workspace, that record builds from the files you already have. Upload the adherence file, the gap report and the wellness list. Ask it to join them on name and date of birth and show every open item per patient. In Rivvi, the joined list lives in the workspace with each patient's open items and opt-out status. The organization's memory can be viewed, edited, corrected or removed by your team.
Join your three lists into one
Upload the files each team uses. Free for you and two colleagues, with a HIPAA BAA.
How to prioritize inside one conversation
One call shouldn't become a 20-minute checklist. Rank items so the most important comes first and the rest fit naturally.
- 1
Join the lists
Combine the adherence, quality and wellness lists. Dedupe on name plus date of birth. Have a person review near-matches.
- 2
Rank the open items
A typical order: a missed medication refill first, then a visit that can close several gaps at once (like an AWV), then single screenings.
- 3
Set the opening
Open with the top item. Then: 'While I have you, you're also due for two screenings. Can we set those up?'
- 4
Hand off what needs a person
When a visit needs booking in the EHR, Rivvi doesn't book into it. It warm-transfers the patient live to your scheduler, or creates a follow-up task with every open item listed.
- 5
Log once, update everywhere
Record what closed and what didn't. Outcomes are recorded in Rivvi and pushed to HubSpot, Salesforce or Zoho if connected. Every team sees the same result.
An AWV is often the best second item. A single visit can cover several open quality measures. Medicare pays about $174 for an initial AWV (G0438) and about $138 for a subsequent one (G0439), 2026 national non-facility rates. Your locality will differ. Patients pay nothing if the provider accepts assignment, which makes it an easy yes on the phone.
If the patient has two or more chronic conditions, the same conversation can introduce chronic care management. CPT 99490 pays about $66 a month (2026 national non-facility) for the first 20 minutes of clinical staff time. CCM requires documented consent, so the call can explain the service and hand off to staff to enroll.
What one conversation sounds like
Here's how a consolidated call might go for Ms. Jones, with three open items: a statin refill that's 20 days late, an open breast cancer screening gap, and no AWV this year.
Open with the most urgent item. "Hi Ms. Jones, this is the AI assistant calling for Dr. Lee's office. Our records show your cholesterol medication is due for a refill. Do you have enough on hand?"
Handle it before moving on. If she's out, note the pharmacy and create a refill task. If she stopped on purpose, flag it for the pharmacist or care team to follow up.
Bridge to the next item. "While I have you, you're also due for your yearly wellness visit with Dr. Lee. That visit is usually covered with no cost to you. Would you like to set it up?"
Bundle where you can. If she says yes, mention that the mammogram order can be discussed at the same visit. Then transfer her to the scheduler.
Stop when she wants to stop. If she's short on time, log what's still open. The next contact picks up where this one ended, because it's in her record.
Two rules keep this from feeling like a sales pitch. Each item ties to her own care, not to a promotion. And the AI asks before moving to the next topic, rather than reading a list.
One consent status for every team
Consolidation only works if consent is consolidated too. Under the TCPA, patients can revoke consent by any reasonable method, including replies like STOP, QUIT or CANCEL. You must honor it within ten business days. The FCC voted on September 30, 2026 to revise parts of the revocation rules, including how revocation applies across message types. Those changes weren't yet published when this was written, so check the current text before launch.
The practical rule is simpler than the law: one opt-out list, checked before every call and text, by every team. Rivvi honors TCPA opt-out on every outreach path, so a STOP on a text also stops the next call.
What this looks like at scale
Southeast Medical Group used Rivvi to reach more than 104,000 patients with a 0.45% opt-out rate (August 2026). One pharmacist reached 30,000 patients, versus about 200 manually. Refill success hit 56%, versus 5 to 10% with manual outreach.
You don't need that scale to start. Pick one high-overlap group, such as Medicare patients on the adherence list who also have open gaps. Join their records, rank the items, and run one conversation each. Then compare the result with how your teams did it last quarter.
For the list-building side, see how to build a care gap outreach list from an attribution file. For the program view, see care gap closure and medication adherence.
One patient, one conversation
Join your teams' lists and see every open item per patient. Free, with a HIPAA BAA.
Sources
- 47 CFR 64.1200, TCPA delivery restrictions
- MS Law Group, FCC finalizes new TCPA revocation rules
- Medicare.gov, Yearly wellness visits
- CMS, Chronic Care Management Services booklet (MLN909188)
- MedFeeSchedule, CPT 99490 (2026 national non-facility)
- MedFeeSchedule, HCPCS G0438 (2026 national non-facility)
- MedFeeSchedule, HCPCS G0439 (2026 national non-facility)
- CMS, Physician Fee Schedule Look-Up Tool