Closing Gaps in Care Toolkit

Addressing gaps in care is an important opportunity to improve patient care and a practice’s quality metrics. Creating an outreach plan to reach specific patient populations based on their conditions can make a gap closure plan more manageable and successful.

Closing gaps in care can lead to a better managed patient population, helping to catch potentially life-threatening illnesses in patients, coordinate needed care and also improve opportunities for more incentive dollars from payers.

A gaps in care plan should include:

    • HEDIS gaps in care reports generated through a practice’s electronic medical record
    • running reports using metrics on tracking tool (provided by your practice resource team (PRT) member)
    • reminder letters to patients listing screenings and tests that are due; follow up with patients via phone calls, texts, emails
    • utilizing patient portals for additional reminders
    • a copy of worked reports and lists in your patient centered medical home binder, along with the tracking tool to go over at PRT visit

Resources for closing gaps in care

Letter template

Patient education materials (various health topics, including cancer screenings, diabetes prevention and management, blood pressure management and more)

Tips for closing gaps in care poster


Social media graphics

Click here for social media graphics that can be used to promote telemedicine, screenings and other health/wellness topics to patients.