5 Ways to Close the Care Gap

Care gaps closures require a lot of care coordination. Here are a few tips on how to manage closing care gaps easily.

Categorized as Guides

Care coordination is an essential component of healthcare reform. Learn how to close care gaps by using these five strategies!

Using the right medical CRM with a patient registry and a dedicated medical call center team helps.


Closing care gaps improves HEDIS scores and promotes higher quality of patient care. Improving HEDIS scores improves your payouts for the following year.

Use a dedicated care coordination team for closing care gaps. Empower the care coordination team with a medical CRM that sits on top of your EMR. Use medical CRM technology to handle closing care gaps as much as possible. Deploy the care coordination team for non-responders.

How to close care gaps

Closing care gaps will fall into a few categories:

  • Recalling patients at regular intervals 
  • Referrals to specialists, closing the loop with the specialists via their consult notes 
  • Lab orders, closing the loop via lab results 
  • Medication orders, closing the loop via medication reconciliation 

Here are 5 tips on closing care gaps easily

  1. Create a care gap report.
  2. Establish a referral network of specialists.
  3. Create a referral network of lab partners.
  4. Establish a referral network of pharmacy partners.
  5. Create or hire a care coordination team to ensure referral appointments are made, patients make it to these appointments and you receive the visit reports.

Closing care gaps – quick wins

You can get quick wins if you schedule all important preventive care at the earliest. Examples include:

  1. Colorectal cancer screening
  2. Breast cancer screening
  3. Diabetes care
  4. Controlling hypertension

Deliver & document appropriate treatment-based care by making sure of the following:

  1. Document all pain assessments.
  2. Promote medication adherence and document medication reconciliation.
  3. Recommend Disease-Modifying Anti-rheumatic Drugs first (treatment of rheumatoid arthritis).
  4. Recommend statin therapy regimen for cardiovascular disease and diabetes.

What are care gaps in healthcare

Your patients have various health conditions. Your peers, NCQA, CMS have already established clinical guidelines / care plans for almost all of those conditions.

These care plans comprise of specialist referrals, screenings, HRAs, diagnostic/imaging and laboratory procedures, medication adherence etc.

Care gaps are simply the delta between the care each patient with a certain condition has received vs recommended practices.

For chronic and high risk “conditions”, your staff has to follow the established guidelines to close care gaps.

Examples of Gap in Care

Closing care gaps involves tending to these scenarios. Here are just a few examples:

  • Patients overdue for age-based screenings. Eg patients 50–75 years of age who should’ve had screening for colorectal cancer, but didn’t.
  • Or patients 18–75 years of age with diabetes (types 1 and 2) whose hemoglobin A1c (HbA1c) were supposed to be controlled, but weren’t.
  • Patients overdue for seasonal screenings.
  • Patients overdue for vaccines. Eg patients 18+ years of age that were due Flu vaccinations but weren’t given one. 
  • Patients who didn’t continue on a statin medication of any intensity for at least 80% of the treatment period 
  • Patients 67 years of age and older who had at least two dispensing events for high-risk medications to avoid from the same drug class

Why are care gaps important

There are multiple reasons for providers to care about closing care gaps.

  1. Patients’ health outcomes and their “ratings” of you.
  2. Payers’ STAR ratings depend on patients’ health outcomes and their “ratings”.
  3. Therefore, your future payouts depend on your how much you help patients and payers “shine”.

Medicare STAR Ratings

Your payers are measured via the Medicare Star Ratings system (scores 1-5). The higher they score on STAR ratings, the more they can sell to employers.

STAR ratings are majorly affected by patient-physician relationship and health outcomes of patients.

Hence, providers are measured by payers based on those factors.

Additionally, payers can reduce their risk exposure for patient populations they insure.

HEDIS Quality Measures

HEDIS quality measures have standardized care plans for patients based on their demographics and health conditions. These measures and clinical guidelines are created from evidence based medicine.

There are over 90 preventive measures.

Resolving care gaps are important for patients to stay in their best possible health.

You achieve higher HEDIS scores by closing care gaps.

While doctors and providers are buried under episodic, acute care, quality measures create a path to move towards population health maintenance.

Population Health Management

Providers can elevate themselves towards managing the health of the patient population under their care, rather than remain buried under the tyranny of acute care.

On top of this, providers under risk sharing agreements get higher reimbursements upon closing gaps in care.

It’s a win-win all around for patients, providers and payers.

What is a care gap report

A “Gaps in Care” Report is created to assist providers with closing the gaps in their patients’ care plans.

Payers create this report quarterly (at least). This doesn’t stop providers from creating these reports themselves. 

Payers create care gap reports by gathering data from their claims system, affiliated labs and immunization registry systems.

Providers can also create these reports proactively by working with their EMR.

How to create a care gap report

Very few EMRs are good at population health management and closing care gaps as you continue with your daily business.

Here are the steps to create care gap reports

  1. Decide on the HEDIS quality measures you’re going to address this year. This gives you a list of patient conditions that you’ll prioritize.
  2. Create a patient registry that identifies patients with those conditions
  3. The care plan is automatically created for you just by adhering to the HEDIS quality measures. If you want to add to the care plan, go ahead and do that 
  4. Go through your EMR and note all the care gaps as of date

That’s about all there is to it.

Close care gaps – referral network

First step is to establish a good rapport with some of the specialists you need to refer to. This includes:

  1. Medical specialties
  2. Laboratories
  3. Diagnostics facilities
  4. Pharmacies

Have a conversation with these partners and make them aware that you’ll be sending them patient orders related to your HEDIS measures. Let the partner staff know that the patients should get appointments asap and you expect visit notes within 48 hours of the patient being seen.

PRO TIP – unless you have the visit note back, you have no proof that you met that specific requirement.

Close care gaps – recall patients

Once you have your specialist network tightened, start working on the patients.

  1. Do not rely on patients making appointments on their own.
  2. You need visit notes / lab reports / diagnostic reports from your referral partners. Do not rely on their staff to get those over to you on time.
  3. Approach the strategy of recalling patients first. Don’t rely completely on this.
  4. You don’t have to bring patients into your office to get them a referral to a specialist, lab, pharmacy or diagnostic facility.

If your patients do take your advice and show up for their appointments, you get the perfect chance to educate them on the importance of “closing care gaps for their preventive care”. 

If your patients do not show up to your own office for their preventive care appointments, they’ll certainly not complete the specialist visits.

Triage and make appointments yourself

Once the patients show up, do not just write the referrals and hand it to them.

Instead, while the patient is in your office or on the call with your staff, call the specialist office and triage with the patient for a confirmed appointment date/time. 

While you’re at it, tell the specialist referral coordinator (or front desk) that you’ll call to remind the patient about this appointment.


Do not leave the onus of reminding the patient, reappointing no shows, recalling cancelled patients on specialist staff.

Closing care gaps – Laboratory and diagnostics

Your care gap closure efforts affect your own payments, so don’t leave your money in someone else’s hands. We take the same approach with surgery scheduling as well.

Take the same approach for laboratory orders too. Triage, set appointments, notify your partner that you’ll handle reminders, no shows, cancellations, follow up for procedure results.

Closing care gaps – Medication Adherence

Medications adherence also follows a similar pattern.

For medications that you prescribe, you usually do not know if your patient has filled the prescription.

If the patient has filled the prescription, you don’t know if they’re taking the prescribed dosages on time. 

Again, take matters in your own hands.

Remind the patient to take their prescribed medications at the prescribed times per day. Using a medication reminder system is the easiest way to get this done.

This is the only way to ensure that your patients are adherent. 

This kind of closed loop care management is not possible without solid care coordination teams.