Care Coordination For Closing Care Gaps 

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

Categorized as Call Center

Quick tips on closing gaps in care. It’s hard to do but not impossible.

What are care gaps in healthcare

Your peers, NCQA, CMS have already established clinical guidelines that make your life easier. For chronic and high risk “conditions”, your staff simply has to follow their guidelines. There are clinical guidelines for the monthly, quarterly and yearly care plan of patients with certain conditions (eg diabetic patients). All your staff has to do, is follow them. 

Care gaps are simply the delta between what the patients with a certain condition have been provided vs best practices (or recommended). That’s it.

Examples of Gap in Care

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

HEDIS quality measures standardize care plans for patients that need it. There are over 90 measures and take a preventive in nature. These measures and clinical guidelines are created from evidence based medicine. While doctors and providers are buried under episodic, acute care, quality measures create a path to move towards population health maintenance.

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

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.

Payers can reduce their risk exposure for patient populations they insure.

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

What is a care gap report

A Gap 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 by working proactively 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

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.

Create a patient registry that identifies patients with those conditions

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 

Go through your EMR and note all the gaps in care as of date

That’s about all there is to it.

How do you close care gaps

Don’t get overwhelmed when you first see the patient registry data and the care gap report.

The 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 
– etc

First step is to establish a good rapport with some of the specialists you need to refer to. You might already have a few favorites that give your patients immediate appointments, always send concise consult notes back to close your referral loop, wow your patients with their care and bedside manner. Have a conversation with these specialists and make them aware that you’ll be sending them patients related to your HEDIS measures, that the patients should get appointments asap and you should get the visit notes within 48 hours of the patient being seen.

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

Approach the strategy of recalling patients first. 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 the 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.

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. Never leave the onus of making an appointment your patient’s responsibility. Never leave the onus of reminding the patient, reappointing them if they’re a no show, recalling them if they cancel – the responsibility of the staff that don’t report to you (ie the Specialist office staff).

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 lab orders too. Triage, set appointments, notify that you’ll handle reminders, no shows, cancellations, follow up for lab results.

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

Reaching out to patients via text, calls, voicemail drops

As you can tell this involves a lot of outreach to patients. Automated communications helps alleviate some of these pains. Use a healthcare CRM that is tied to your patient registry to guide the care gap outreach campaigns. However, do not leave the outreach in the hands of technology alone. 

Even if technology is able to solve 50% of your outreach efforts, that’s 50% less work your staff has to do. 

Your technology choice should allow you to 
– send text messages automatically as part of a predetermined campaign 
– allow you to create various templates of messaging so you can experiment with and determine what messaging works and what doesn’t 
– allow you to have 2 way communications with your patients. Trust me, patients tend to reply back to the text message they receive .. whether you monitor that text message inbox or not. 
– send your campaign message as a voice note for phone numbers that are landline numbers 
– even better, call patients with a pre recorded campaign message and allow patients to “press one to talk to our care coordinator now”. In other words, it should tie into your phone tree / IVR 
– if you don’t have the staff to answer phone calls, then allow patients to make appointments by themselves 24/7. Most EMRs already have some functionality to allowing patients to book appointments themselves – use that feature 
– escalate non respondent patients to your care coordinators or someone else that you designate. Don’t wait until the end of the year or month to get “reports”. This doesn’t leave you with much time to actually act on them

Contact Sales


    How did you hear about us?

    How can we help?