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What are Gaps in Care and How to Close Them (Examples)

Disclaimer: Virgin Pulse and HealthComp are now Personify Health

Gaps in care is a common term used in the healthcare industry, but what is a gap in care and why is it so important to close them? We’ve got the answers you need to understand why closing gaps in care is good for health, and business too.

What is a gap in health care?

A “gap in care” is defined as the discrepancy between recommended best practices and the care that’s actually provided. For example, here are some common gaps in care:

  • A person is overdue for a recommended screening – like an annual mammogram, colonoscopy, or well visit – based on their age or other risk factors
  • A person doesn’t follow the recommendations for taking a prescription medication to manage a specific condition like diabetes
  • A person doesn’t share with their provider how a newly prescribed medication from another doctor might interfere with their current medication
  • A person can’t find or access the care they need in their network or area

To address these issues, numerous examples of gaps in healthcare highlight the urgent need for systemic changes.

Why is it important to close care gaps?

First and foremost, adhering to recommended preventive care, like getting an annual cancer or diabetes screening, lead to better health outcomes due to early diagnosis or maintenance of a chronic condition. When certain conditions are caught early, treatment can start sooner, leading to lower healthcare costs and higher quality of life.

Health plans want their members to be healthy and keep healthcare costs down, but they are also focused on closing gaps in care in order to maintain or improve quality measures (CMS Star Ratings and HEDIS Measures). These quality measures are important because they contribute to how health plans are reimbursed for care and how they are able to market their plan in the future.

Efforts to reduce gaps in care are crucial in achieving this goal, ensuring that all individuals receive the care they need when they need it.

Are some gaps more important to close than others?

Some quality measures are triple weighted – like medication adherence for diabetes, hypertension and cholesterol. However, all gaps in care are important to address, because if there’s a gap, it means a person isn’t receiving the recommended care.

How can you identify gaps in health care?

Common ways to identify a gap in care are to talk with an individual (Did you have your annual mammogram this year?) or to review clinical/claims data to track if a service was provided.

A more proactive way to closing gaps in care is combining clinical/claims data with consumer data and applying predictive analytics to identify who is at-risk for a gap based on things like SDOH factors – things that are happening outside of the clinical world that may lead them to put off care or miss a medication refill. These insights are helpful because they give a plan time to know early on who might need a little extra nudge to come in for that recommended screening, instead of waiting for the last two months of the year to see who needs outreach to close the gap.

Innovative strategies are essential to close the care gap, utilizing technology and personalized care coordination.

What are the best ways to get people to close a gap in health care?

Once you know who is at risk for a gap in care, organizations can conduct targeted outreach campaigns to reengage people in care. Personify Health’s predictive analytics help, by not only identifying who is at risk, but also by identifying who is likely to be receptive to outreach and take action based on it.

For example, with our predictive models, a plan can identify which members with diabetes are at highest risk of missing their annual eye screening. We can help that plan conduct targeted outreach across multiple communication channels, like email, text, direct mail, automated voice (IVR) calls, to encourage them to schedule and keep their appointment. Incorporating incentives, like a $20 gift card upon completion of the screening, is another way to boost compliance and close more gaps in care. Personify Health does that too!

Closing gaps in care is important for so many reasons. If you need help getting your members, patients or employees to reengage and close gaps for important screenings, medications or other services, let’s talk.