Quality Score Optimization: How to Identify (And Close) Gaps in Care

Every healthcare provider wants to deliver better care for its patients, but many feel their hands are tied: with an overwhelmed workforce and limited budget, what can you do to improve treatments and enhance your reputation? 

This article explores how closing care gaps can dramatically improve patient outcomes and providers’ bottom-line – and why a simple app could be the key to achieving all that. 

Defining Care Gaps 

A care gap is a discrepancy between established medical best practices or guidelines and the actual care provided. Common examples of best practices include: 

• Tests and Screenings: A patient is “due” a test or screening based on either their demographic or risk factors.  

• Condition Management: A patient has a medical diagnosis, such as diabetes, where their condition requires regular monitoring. 

• Follow-Up: A patient has been discharged from the facility and is expected to either receive a follow-up appointment or support to help with their transition home. 

Failure to adhere to these best practices would constitute a gap in care – and have a range of effects on the patient and provider. 

Note: A care gap implies a failure on the part of the provider, not the patient. The American Journal of Medical Quality points out that treatment gaps are often the result of patient non-adherence, such as refusal to take medication. However, this would not typically be considered a “care gap” – unless the provider has not, for example, provided the patient with an up-to-date prescription. 

Three Ways Care Gaps Impact Providers 

1. Care Quality and Patient Outcomes 

Medical guidelines and best practices exist for one reason: to ensure patients receive timely, effective treatment – and ultimately are healthier and safer. This is the clearest and most devastating effect of care gaps: they compromise the quality of care your organization delivers. 

Care gaps often result in delayed interventions, where treatments or necessary services are missed or postponed, leading to worsening health conditions. These delays increase the risk of preventable complications, which can escalate to hospitalizations or even mortality. Furthermore, care gaps contribute to lower preventive care rates, as patients miss vital screenings or vaccinations, allowing chronic diseases to progress unchecked. The latest estimates suggest nearly 100,000 deaths could be prevented each year with timely interventions. 

There are also psychological effects: discontinuity in the care process can negatively impact patients’ trust and confidence in the treatment, which can make an already challenging experience even worse.  

2. Provider Performance Metrics 

Care gaps undermine providers’ success in meeting quality metrics critical to value-based care programs like Healthcare Effectiveness Data and Information Set (HEDIS) or CMS’s Merit-Based Incentive Payment System (MIPS). 

Poor performance on these measures can impact quality scores and financial incentives. Additionally, unresolved care gaps negatively influence patient satisfaction, leading to diminished trust, damaged reputations, and lower patient retention. 

3. Financial Impact 

Care gaps have a measurable impact on many providers’ financial health. This is caused by several factors, including: 

• Increased Patient Churn: Many patients will note care gaps, especially as the internet has granted greater access to accurate medical guidelines. As a result, care gaps have been known to reduce patient retention and ultimately the provider’s bottom-line. 

• Missed Revenue Opportunities: For example, billable services such as screenings, follow-ups, and chronic care management are often overlooked. 

• Reduce Reimbursements: Care gaps often mean providers miss performance benchmarks and either miss out reimbursements or receive penalties from health plans. 

• Inaccurate Risk Adjustment: Care gaps, particularly in chronic condition management, lead to inaccurate risk scores, underreporting the complexity of patient populations and resulting in inadequate compensation. As a result,  

In summary: Care gaps harm patients, as well as providers’ reputation and financial well-being. So why would anybody allow them to persist? 

What Causes Care Gaps? 

Care gaps arise from a variety of systemic, administrative, and operational challenges that hinder the delivery of timely and effective care. The term “gap” is key: most care gaps are caused by a disconnect between information and the administrators or physicians charged with actually managing and delivering care. 

These disconnects have several causes: 

– Resource Scarcity: There may simply not be enough physicians available to meet all care requirements. Many practices already have a large backlog of patients to see, which inevitably leads some to receive care later than ideal. 

– Fragmented Data: Healthcare data is routinely stored in multiple systems with limited interoperability. This means physicians do not have a complete view of their patient’s medical history, nor do they have a clear list of care gaps easily to hand 

– Lack of Awareness: In some cases, practices simply lack a comprehensive overview of their existing care gaps. This makes it difficult to proactively work through the list, meaning many either get lost or overlooked for a long time. 

How to Identify Patient Care Gaps 

There are many established ways to gain a more accurate view of existing care gaps: 

• Use EHR Systems Effectively: Leverage electronic health record (EHR) systems to set up automated alerts, dashboards, and reminders for overdue services. These tools ensure that providers are notified in real-time about missing screenings, follow-ups, or preventive care needs. 

• Leverage Advanced Analytics: Implement population health management tools, predictive analytics, and AI to identify at-risk patients who may fall through the cracks. These insights allow for targeted interventions to close gaps before they worsen. 

• Analyze Claims Data: Cross-referencing claims data with clinical records can reveal missed services, such as unperformed tests or treatments. This approach provides a comprehensive view of care gaps across the patient population. 

• Monitor Quality Metrics: Regularly review performance metrics such as HEDIS, MIPS, and other benchmarks to track care gaps systematically. By analyzing these metrics, providers can pinpoint areas needing improvement and ensure alignment with value-based care goals. 

• Conduct Chart Audits: Periodic chart audits focusing on high-risk groups help uncover gaps that might otherwise go unnoticed. This is particularly useful for managing chronic conditions or ensuring compliance with preventive care guidelines. 

• Collaborate with Payers: Sharing data with insurers and external organizations offers a broader perspective on patient care, allowing providers to identify and address gaps that may not be apparent from clinical records alone. 

• Generate Real-Time Care Gap Reports: Proactively track and address gaps by generating real-time reports. These reports allow healthcare teams to prioritize critical interventions and measure progress in closing gaps. 

However, the biggest challenge for many practices is not identifying care gaps – it is equipping their physicians to address them effectively.  

That is why we created the Care Gaps App: a simple tool that enables providers to easily upload a list of care gaps and integrate them directly within the EHR. This gives your physicians everything they need to understand and close care gaps at the point of care, with a straightforward system to reject irrelevant gaps and log successfully closed ones in the EHR with a single click. 

Want to see how it could help you improve patient care and boost your quality scores? 

Book a Demo