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What Are Gaps in Care and How to Close Them

Jon-Michial Carter
Written by Jon-Michial Carter

Annually, gaps in care cost the U.S. healthcare system a staggering amount of time and money. When left unaddressed, gaps in care squander healthcare resources, exacerbate chronic conditions and preventable diseases, and increase the workload on already overburdened healthcare systems. 

Medication non-adherence alone is estimated to cause 125,000 deaths each year. In the absence of properly managed care, critical diagnoses can be delayed or missed altogether. This can lead to escalating treatment costs, more invasive surgeries, and deteriorating quality of life. When patients don’t adhere to treatment plans, comply with recommended screenings, or take prescriptions as instructed, the consequences can be dire. 

Closing gaps in care not only transforms patient health outcomes, it is also financially advantageous for healthcare practices. Eliminating care gaps improves quality scores and increases reimbursements for value-based care and quality improvement programs. 

However, identifying and closing gaps in care requires intensive effort and resources. 

In this article, we will explore how to identify and address care gaps effectively. And we’ll share how Annual Wellness Visit software and a Chronic Care Management program can help you improve patient outcomes and maximize quality scores by identifying and working to close gaps in care among patients. 

What is a gap in care?

A “gap in care” is created when the care provided to a patient is inconsistent with the recommended best practices in healthcare. For example, if a patient is in a high-risk category for breast cancer and has not received an annual mammogram, this lack of insight into their cancer status presents a gap in the patient’s record. Their primary care provider cannot manage or take action on what has not been measured. 

Gaps in care manifest in a wide variety of ways. Missed screenings, failure to reschedule wellness visits, improper medication adherence, and inability to find in-network specialists can all interrupt a patient's journey toward optimal care. The risk of undetected conditions developing into serious health concerns heightens the longer these care gaps go unresolved.

Examples of gaps in care 

Undiagnosed diseases, the lack of access to effective treatments, non-adherence to prescriptions and medical advice, and restricted access to necessary healthcare services are all primary drivers in the creation of gaps in care. Gaps in care are also created due to infrequent communication or unclear directives from a patient’s primary care provider. Gaps of care might refer to a patient who: 

  • does not take medications as prescribed
  • does not undergo recommended screenings, like mammograms, colonoscopies, depression screenings, or cardiovascular screenings
  • does not receive the testing necessary for managing a chronic illness
  • does not schedule recommended appointments like annual wellness visits or behavioral health appointments 
  • is missing recommended vaccines and boosters 
  • is unable to arrange transportation to appointments 
  • has diagnoses, medications, or test results that are not shared between primary care physicians and specialists 
  • is unable to find the care they need within their network or area

When a patient is not adhering to the medication prescribed to manage their chronic conditions, this creates a significant gap in care. Studies demonstrate that approximately half of patients with chronic diseases do not take their medication in accordance with their prescriptions. Further research indicates that after the first year of diagnosis, approximately 50% of patients with chronic conditions stop refilling their prescriptions

Social Determinants of Health (SDOHs) can create these gaps in care. Patients may be unable to afford their medications and treatments or unable to arrange transportation for clinical visits. Patients may also feel overwhelmed and that their care providers are not providing them with the support needed to manage their conditions. On the other hand, chronically ill patients feel healthy and see no need to pursue additional screenings or tests.

When patients fail to follow through on recommended screenings, diagnoses can be missed. This presents an obvious gap in care that can have a deleterious impact on the patient’s health.

Early detection of disease leads to proactive treatment plans that can mitigate patient suffering and increase quality of life. Therefore, it is vital for patients in at-risk groups to comply with recommended health screenings. 

Closing gaps in care extends beyond preventative measures to patients currently managing chronic conditions as well. For example, patients with diabetes should be receiving A1C testing anywhere from twice a year to every three months, depending on the severity of their condition. These tests are essential for monitoring the efficacy of diabetes treatment plans. When these are missed, healthcare providers do not have the necessary data to evaluate the success of the treatment programs. 

A Chronic Care Management Program (CCM) can help with gaps in care

A Chronic Care Management Program enables consistent and personalized communication that helps keep patients on track with their treatment plans. ChartSpan’s Chronic Care Management program provides your practice with a dedicated care team who contacts each enrolled patient monthly. Our services allow for real-time monitoring of the obstacles patients encounter with their self-managed care. 

If patients are struggling with prescription refills, side effects, or medication costs, or do not understand the importance of taking their medications, the care team member can offer assistance. The care team can also assist patients with transportation services, and appointment scheduling, and remind patients of upcoming screenings, vaccinations, A1C draws, and wellness appointments.

Our CCM program seamlessly integrates into your preexisting workflow and requires no additional labor on your part. ChartSpan’s CCM program also incorporates at least twelve communication touchpoints into enrolled patients’ care journeys every year. The frequency and consistency of this communication are key to the identification of gaps in care. ChartSpan’s care team members address upcoming screenings, missing vaccinations, and with each patient monthly.

For example, your healthcare organization may have identified hundreds of patients in their practice who have not received recommended cancer screenings. ChartSpan can take this list and populate alerts on the charts of all the identified patients. When it is time for those patients to receive their next monthly call, our care team will see this alert. We can then discuss the identified gaps with patients during their monthly calls. 

Our program also provides patients the opportunity to actively engage in the management of their conditions. We can provide digital or printed collateral about symptoms, daily management tips, and guidance on when to call the 24/7 nurse line. When patients are educated about their conditions, they are motivated to follow through on necessary risk screenings and health assessments. 

Learn more about how applying the Chronic Care Model can help patients achieve their health goals.  

Why it’s important to identify gaps in care

Identifying gaps in care is crucial to facilitating positive clinical outcomes for patients and enhancing quality scores for your practice. Healthcare providers cannot manage conditions that have not been identified. When the window for early diagnosis is missed, so is the opportunity for implementing proactive treatment and maintenance plans. 

Identifying gaps in care allow patients to be ideally positioned to treat their chronic conditions early and effectively, leading to improved quality of life and lower healthcare costs. 

How do gaps in care affect providers?

When gaps in care exist, you miss opportunities to provide essential services to patients and receive reimbursement for them. Gaps in care may also contribute to poor performance in meeting quality measures, leading to financial penalties or reduced reimbursements.

Additionally, treating preventable complications, managing advanced disease stages, or providing emergency interventions can be more expensive than providing timely and preventive care. You may incur additional expenses in the form of extended hospital stays, specialized treatments, or costly procedures.

Identifying and closing gaps in care leads to improved scores under Medicare’s Merit-based Incentive Payment System (MIPS) and other quality improvement programs. MIPS is a part of the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP). MIPS endeavors to move Medicare reimbursements toward value-based payments, emphasizing high-quality care, cost efficiency, and improved clinical outcomes for patients. 

MIPS, however, is a complex program that many healthcare providers find challenging to manage alone. ChartSpan’s CCM program comes with a dedicated MIPS consultant assigned to your practice, as well as a dynamic reporting dashboard that gives you real-time insight into your MIPS scores.

Improve your quality scores with ChartSpan

Our CCM team will help identify gaps in care among your patient population and individually work with patients toward resolving them during their monthly calls. This is not only beneficial to the health of the patient but also to your quality scores. 

Your practice can report on CCM-assisted care gap closures under the Improvement Activities section of MIPS. The Quality and Cost performance metrics of MIPS scoring also benefit when care gaps are closed, as a patient who receives screenings and vaccinations and follows guidance on managing their chronic conditions is more likely to experience high-quality care and require fewer expensive interventions. 

Healthcare providers who partner with ChartSpan have the opportunity to increase their Medicare fee-for-service reimbursements by 9% over 36 months through MIPS compliance. Our MIPS consultants will also assist your practice in tracking quality initiatives and billing CCM codes. Practices that enroll 300 patients in our CCM program can earn over $100,000 per year in net new revenue with CCM CPT Code #99490 (though this figure varies by state and practice type).  

Learn more: How Chronic Care Management Earns Recurring Revenue for Your Practice

How do gaps in care affect patients with chronic conditions?

When patients are balancing multiple chronic conditions, the risk of unaddressed gaps in care is compounded. These patients are often juggling multiple prescriptions, appointments with various specialists, and numerous lab results. They may already feel overwhelmed or fatigued by their medical responsibilities. 

As a result, these patients may be less likely to independently pursue recommended annual screenings or follow the recommended dosage on their prescription medications. They often require more attentive guidance to help them manage their care plan.

Furthermore, patients with chronic conditions are more likely to experience poorly coordinated care. These gaps in care coordination may cause patients to experience conflicting communication between multiple providers and specialists, repeated or unnecessary tests, adverse drug interactions, and increased healthcare costs. 

When a patient is managing multiple chronic conditions, their path to positive clinical outcomes hinges on the elimination of these healthcare gaps. A holistic picture of the patient’s medical situation allows healthcare providers to develop informed wellness plans.

Addressing gaps in care can be difficult, and you may not have the time or resources to comb through patient records and identify gaps, much less reach out to each patient and create plans to close them.

ChartSpan’s CCM care team maintains monthly contact with enrolled patients. This regular cadence of communication allows us to plan care coordination for patients proactively. It also allows us to ascertain obstacles each patient encounters with their care plans to help you facilitate a solution before the gaps in care even emerge. 

Healthcare providers may only get two to three chances per year to have face-to-face visits and address care gaps. Through ChartSpan’s CCM service, patients have twelve or more additional touchpoints conducted at regular intervals throughout the year. 

The results of these calls are all documented through a care plan shared with you through your existing EMR. This documented information provides you with current and complete patient data so you can maximize your time in person with patients.

Learn more about how Chronic Care Management can relieve practice workload.

What causes gaps in care?

Gaps in care coordination 

Patients managing chronic conditions are more likely to see multiple providers. This presents a challenge when the exchange of patient information is not properly coordinated between clinicians. If patient information is not shared, their health picture remains incomplete. These gaps in care, also known as gaps in care coordination, can lead to duplicate tests, overuse of prescription medication, avoidable hospitalizations, and patient confusion and frustration.

How ChartSpan’s CCM program closes gaps in care

Monthly conversations allow ChartSpan to spot redundancies or potential complications arising from multiple channels of care. If the ChartSpan care team learns that the patient has received a risk screening at a separate medical organization, they can send a medical record request on behalf of their client. When ChartSpan receives the copy, it can be added to the patient’s record, eliminating a gap in care coordination. 

Additionally, ChartSpan’s CCM care team can check in monthly with patients on any new medications they may have been prescribed by other providers and note this in the patient’s documentation. They can also observe if the patient seems to be frustrated by poor communication between care providers and work to resolve the gaps in care coordination. The care management team at ChartSpan rigorously documents the results of their monthly patient outreach and gives these records to patients’ healthcare providers.

Lack of access to healthcare services 

A lack of access to in-network or local care can cause patients to stall or forgo treatments. If a patient is unable to schedule their health assessments promptly, they may abandon the practice for another one. Patients with mental health conditions may turn to Emergency Room services if they are unable to find in-network psychiatric assistance. All of these are gaps in care created by a lack of access to services.

However, a patient’s inability to access healthcare services can also arise due to their financial situation or social health. Patients who cannot afford their medications may find themselves having to choose between filing a prescription and feeding themselves for the month. If a patient is unable to drive and does not have the resources to arrange for transportation, they are unable to access the screenings and consultations necessary to manage their conditions.

How ChartSpan’s CCM program extends access to care

ChartSpan’s CCM has the resources to help patients’ social health as well as their physical health. When the ChartSpan care team learns of financial difficulties affecting a patient, they can connect them to resources like food pantries, pharmaceutical discounts, transportation to medical providers, rent and utility assistance, and more. This investment in the patient’s social and physical health builds stronger relationships with the patient while preventing gaps in care from arising due to inaccessibility. 

Learn more: How Chronic Care Management provides access to care

How to close gaps in care

1. Educate and engage patients

Patients are more motivated toward positive behaviors when they have been meaningfully educated about their conditions, medications, and risk factors. Studies indicate that patients who take an active role in their health care often have more positive clinical outcomes. When you educate patients on their chronic conditions, patients are better positioned to become involved in their ongoing chronic care management. 

Emphasizing the crucial role preventative care plays in long-term health and overall quality of life can encourage patients to follow through with recommended risk screenings. Communicating the danger of discontinuing medication without prior medical consultation can motivate patients to adhere to prescription plans. 

Education can also help patients abstain from choices that can worsen chronic illnesses. Patients who understand the risks gaps in care pose to their health have a greater motivation to resolve these discrepancies. 

2. Communicate consistently 

Consistent communication with patients closes gaps in care swiftly and efficiently, facilitates patient education, and builds patient trust. When patients see the benefits of sticking with their care plans actualized, they are more likely to continue actively participating in their care management. Regular calls provide accountability, which may inspire some patients to follow through on their recommended wellness plans. 

Consistent communication also allows for misinformation to be addressed promptly. Many people turn to the Internet to research their health questions. While there is a wealth of valuable medical information available online, there is also a vast array of anecdotal and inaccurate claims. 

When a patient has recurring calls with a CCM care management team, they can ask them about the information they’ve encountered online. The care team then has the opportunity to steer the conversation away from the potentially misleading research and refocus the conversation on the root of the patient’s concerns. 

3. Address Social Determinants of Health (SDOH)

Social determinants of health can create critical barriers to care access and contribute to gaps in care for patients. Overcoming these hurdles is paramount to providing patients with preventative care. The financial strain of managing chronic conditions is one of the most obvious SDOH barriers. Patients living on a fixed income may struggle to afford their prescriptions, and forgo medication to purchase food or pay their rent. 

Chronic Care Management providers can connect patients to resources that alleviate financial insecurities. This helps prevent economic precarity from disrupting early disease detection and care management.  

Transportation access is another social health hurdle that can create gaps in care. If a patient is unable to drive themselves or arrange for transportation, they are at risk of missing appointments and screenings. Our care team closes this gap in care by discovering and arranging for transportation services for the patients. These services are often covered by Medicare. 

4. Conduct Annual Wellness Visits

Annual Wellness Visits (AWVs) facilitate rapid identification and closure of care gaps. AWVs are completed annually by Medicare recipients and help providers create personalized prevention and care plans for individual patients. 

An AWV Health Risk Assessment (HRA) should specifically ask patients about preventative screenings, like pneumonia shots, colorectal exams, or mammograms. Based on the patient’s answers, you can identify and follow up on care gaps during the visit. You may be able to close some gaps, like the administration of an influenza vaccine or an A1C draw, during the patient’s visit. If a patient is missing bloodwork or risk screening, the healthcare provider can schedule the appointment for the patient while they’re in the office. 

Learn more about Annual Wellness Visits: 

Partner with ChartSpan to identify and close gaps in care

Identifying and closing gaps in care requires a dedicated team focused on continuous patient education, communication, and care management. With ChartSpan’s CCM program, you receive a care team dedicated to extending communication and care beyond in-person visits to help your practice address gaps in care. Through our AWV software, every visit is maximized, and care gaps can be identified while the patients are still in the waiting room of your practice.

Identify gaps in care with ChartSpan’s AWV software

ChartSpan’s RapidAWV™ allows you to aggressively target care gaps and work with patients to close them, all without disrupting practice workflow. Our software collects data through a customizable Health Risk Assessment (HRA) that can be completed while a patient is in the waiting room for their scheduled appointment.  

Patient data is gathered quickly and seamlessly, immediately illuminating care gaps so you save valuable time with comprehensive patient health insights before the appointment even begins. Streamlining scheduling and providing vaccinations on-site further saves time and closes gaps in care. 

Close gaps in care with ChartSpan’s CCM program 

A patient who is unsure about the importance of an upcoming colorectal screening may decide to cancel it. However, if this patient is contacted by our care management team beforehand, the patient has the opportunity to voice their concerns before forgoing the appointment. A care team member can then emphasize the importance of preventative care to the patient and explain the risks incurred by canceling the screening. Such communication allows for real-time intervention and the closing of a potential gap in care.  

ChartSpan empowers your healthcare practice to identify and address gaps in care. Our RapidAWV™ software maximizes the patient data gathered during visits, giving your physicians the information needed to close gaps in care during regularly scheduled appointments. Through our CCM program, patients are in touch with a dedicated care team every month. This consistent communication identifies and pre-emptively closes care gaps before they become problematic. 

Contact us to learn how ChartSpan’s comprehensive approach to closing care gaps can improve clinical outcomes for your patients and quality scores for your practice. 

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