Closing Care Gaps, With Whole Person Care Coordination

At Matrix Medical Network, we believe quality care extends beyond the exam room into the home, the community and the spaces in between. For more than 25 years, we’ve delivered in-home health assessments and whole-person care coordination designed to support, educate and empower individuals on their path to better health.

One of the most impactful ways we do this is by helping our clients identify and close care gaps for the people they serve.

Understanding Care Gaps

A care gap occurs when an individual misses a recommended service, screening or follow-up. Common examples include:

• Undiagnosed or unmanaged chronic conditions
• Missed preventive screenings
• Unaddressed medication issues
• Mismanagement of medications
• Social factors, like transportation or housing challenges, that limit care access

Left unresolved, these gaps lead to poorer outcomes, less equitable care and higher costs.

How Matrix Closes Care Gaps

Meeting Members Where They Are: Our in-home approach enables us to see the full picture of health, from environmental risks to social and emotional needs that may not surface in a clinical setting.

Clinician-Led, Whole-Person Assessments: Matrix’s network of nearly 3,000 nurse practitioners conducts comprehensive in-home visits that include diagnostics, health risk identification, social determinants of health analysis and care planning. This allows us to uncover and document care gaps while in the home environment.

Connecting the Dots: Once a gap is identified, our clinicians bridge the divide by coordinating follow-up care, connecting individuals to local resources and reporting back to our client partners. This ensures that identified gaps become closed loops, not a costly miss.

Partnering for Scale and Impact: Through collaborations with engagement and outreach leaders like Carenet Health and Linkwell Health, we help clients reach more members, personalize communication and drive measurable improvements in gap-closure rates.

The Impact of Closing Care Gaps

Closing care gaps delivers meaningful benefits across every level of the healthcare ecosystem. 

Individuals experience improved outcomes through timely care, preventive screenings and more consistent management of chronic conditions. Health plans and providers see measurable cost savings as complications and avoidable hospitalizations decline. 

At the same time, in-home care promotes greater health equity by reaching people who might otherwise face barriers related to transportation, access or social determinants. And for clients focused on value-based care, Matrix’s approach aligns directly with key quality and performance metrics. 

For example, when a home visit reveals an unmanaged condition or missed screening, our team helps reconnect the individual with their primary care provider, reconciles medications and activates community resources—transforming a gap into a meaningful intervention that drives better health for both the member and the organization.

Looking Ahead

As healthcare continues to shift toward value-based, person-centered models, closing care gaps will remain essential. Matrix is proud to partner with organizations nationwide to advance access, improve outcomes and deliver whole-person care where it’s needed most — in the home.