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What is a gap in care and how can independent practices close care gaps?


When you have a patient who is not following up with recommendations for screenings or immunizations, that is considered to be a gap in care. When a patient is not taking prescribed medications as instructed, that is a gap in care. Essentially anytime you have a patient who is not getting the care needed, there is a gap. As an independent physician, however, you can help close care gaps for your patients.

Gaps in care can manifest in several ways, the most common of which include:

  • Individuals who are missing age-based or annual screenings or vaccines
  • Individuals who do not consult with you, as their physician, over a prescribed medication that might not be appropriate
  • Individuals who are not adding a medication to meet evidence-based guidelines.

How can independent practices close care gaps? Developing a long-term relationship with the patient is a critical step in the process. Understanding the patient’s specific needs and how to address them – including any social determinants of health that may affect that patient’s desire or ability to follow through with healthcare instructions – is essential to closing the gap in care.

Learn how to more effectively engage with your patients using the Elation Health Patient Passport.

The more the entire healthcare team at your practice can prepare for and be aware of the patient’s needs during each visit, the better the opportunity to provide care beyond the reason for the visit. There are three critical priority areas for your independent practice to work on, to be able to close the gap in care for your patients.

Deliver a better patient experience that is focused on outcomes. Preparing ahead of the visit, reviewing notes in the patient’s electronic health record (EHR) ahead of time rather than in the exam room, can make a huge difference in developing that necessary relationship with the patient. Being more aware of and emphasizing the need for screening can also help to close the gap in care for your patients.

According to the Centers for Medicare and Medicaid Services, the median performance data for Accountable Care Organizations (ACOs) shows that just 50% of patients receive cancer screening tests, 50% of patients with diabetes have well-controlled HbA1C levels, and 50% of patients with hypertension have controlled blood pressure.

Drive patient outreach that is focused on specific care needs and getting the right patients “in the door.” As an independent physician, think more proactively about your patient populations, especially those who need the greatest amount of care. Reach out with new options for your patients, particularly during the COVID-19 pandemic, such as telehealth visits, phone calls, or portal messages from a member of the care team.

Identify follow-up care, and ensure patients get it, at a reasonable cost. According to a survey from Westhealth Institute and NORC at the University of Chicago, 40% of Americans admit to skipping a recommended medical test or treatment due to affordability. To work toward closing the gap in care, focus on engaging your patients with necessary follow-up care, whether that is via telehealth, a referral, or ensuring price transparency for medications.