Patient Engagement & Care Utilization Dashboard

This dashboard helps you understand how patients in the latest roster are engaging with care and using health center services. It’s a library dashboard, meaning you can use it as-is, or customize it to meet your health center’s needs.

Why rosters?

Rosters are used to represent a list of patients associated with a plan, program, or care initiative. These are generally not housed in the EHR, but imported from external sources.

This allows you to evaluate engagement and care utilization for a defined set of patients, including those who may not be fully represented in EHR data.

Patient engagement gaps

Patients who have not been seen in one or more years, or ever, may be at risk of unmanaged conditions, missed preventive care, or disengagement from the health center. These gaps can be especially important when managing rosters, where consistent engagement is tied to quality performance or contractual goals.

Health centers can use this information to drive re-engagement efforts, such as scheduling outreach, care coordination, or targeted campaigns to bring patients back into care.

Care utilization by risk level

Comparing utilization patterns against patient risk levels helps identify where care is misaligned with patient needs.

High-risk patients with low utilization may not be receiving the level of care needed to manage complex conditions, while low-risk patients with high utilization may indicate inefficient use of resources. Patients who are high-risk but not enrolled in care management represent a key opportunity for intervention.

By segmenting patients in this way, health centers can prioritize care management enrollment, adjust outreach strategies, and ensure resources are directed toward the patients who need them most.