Recognize Patient Care Gaps and Improve Care

In today's complex healthcare landscape, achieving true population health - where every individual receives the right care at the right time - is a challenge. The largest obstacle? Care gaps.

A care gap occurs when a patient has not received a recommended or necessary service based on established clinical guidelines, preventive schedules, or their individual health status. Whether it's a missed annual screening, a lack of follow-up for a chronic condition, or non-adherence to a medication regimen, these gaps lead to poorer outcomes, avoidable complications, and increased costs.

n recent years, these challenges have intensified, particularly for rural communities with limited access to primary care and mental health services.

What Are Care Gaps?

Care gaps are not just theoretical; they are quantifiable events identified by comparing patient data against evidence-based protocols (like HEDIS and Stars measures). They reflect breakdowns in health care access and can include:

Preventive Care

Missed mammograms, colonoscopies, breast cancer screenings, or routine vaccinations (e.g., flu, pneumonia).

Chronic Disease Management

A diabetic patient without a recent A1c test, or a patient with cardiovascular disease lacking an annual eye exam or follow-up visit.

Post-Acute Care

A patient not scheduled for a follow-up visit after a hospital discharge.

Medication Adherence

Patients who stop taking essential medications for conditions like hypertension or high cholesterol.

Mental Health Care

Gaps in mental health services, including missed therapy appointments or lack of access to mental health professionals for ongoing treatment.

The Power of Proactive Identification

Our platform shifts the focus from reactive treatment to proactive health management. We utilize advanced analytics and machine learning to systematically identify care gaps across your entire patient population in real-time.

Unified Data Aggregation

We integrate and harmonize data from every source—EHRs, claims, labs, and pharmacy—to create a single, comprehensive view of each patient's health journey. This complete picture is the foundation for accurate gap detection and improved healthcare research capabilities.

Advanced Algorithmic Scoring

Our system applies sophisticated algorithms to flag patients who fall out of compliance with key clinical protocols. Instead of generic alerts, we provide prioritized, actionable lists that tell your care team which patient has which gap and how critical it is, empowering health care professionals to act decisively.

Targeted Intervention Workflows

The goal isn't just to find the gaps—it's to close them. We provide customizable workflow tools that empower your care teams to:

Segment Patients: Group patients by gap type, risk score, and preferred communication method.
Automate Outreach: Deploy personalized communication (text, email, patient portal messages) to schedule appointments or educate patients.
Measure Impact: Track the effectiveness of every intervention in real-time and see immediate improvements in quality metrics.

The Outcomes: Better Health, Better Business

Closing care gaps is not merely a clinical imperative; it is an economic necessity for health care organizations operating under value-based care models. As public health priorities continue to evolve, proactive gap closure supports both individual patient wellness and broader population health goals.

Outcome	Clinical Benefit	Financial Benefit
Improved Quality Measures	Higher rates of critical screenings and effective chronic disease control.	Drives improvements in HEDIS and Star Ratings, leading to greater reimbursement and bonuses.
Reduced Medical Expense	Prevents the progression of disease, minimizing costly hospitalizations and emergency room visits.	Lowers the Total Cost of Care per member.
Enhanced Patient Trust	Demonstrates a commitment to the patient's long-term health and well-being.	Increases patient satisfaction, retention, and loyalty.

Frequently Asked Questions

What is the difference between a care gap and a health disparity?

A care gap refers to a specific instance where an individual patient has not received recommended health care services based on clinical guidelines. Health disparities, on the other hand, describe broader systemic differences in health outcomes and access to care that affect entire populations, often based on factors like race, ethnicity, income, or geographic location. While care gaps are individual and actionable, they often reflect underlying health disparities within a community.

How does closing care gaps improve health equity?

Closing care gaps ensures that all patients, regardless of their ethnic group, gender identity, sexual orientation, marital status, or socioeconomic background, receive timely and appropriate medical care. By systematically identifying and addressing missed services, health care providers can reduce disparities and work toward equitable access to quality health services for every patient.

Why are care gaps more common in rural communities?

Rural areas often face significant barriers to health care access, including physician shortages, limited availability of professionals, and fewer specialized health care services. Community members in these regions may also have limited access to health insurance coverage, making it harder to afford preventive care and prescription medications. These factors combine to create higher rates of care gaps in rural populations.

How does your platform help health care professionals prioritize patients?

Our platform uses advanced algorithmic scoring to analyze patient data and identify which individuals have care gaps and how urgent each gap is. Health care professionals receive prioritized, actionable lists that allow them to focus their outreach efforts on patients with the most critical needs, improving healthcare quality and operational efficiency simultaneously.

What role do social determinants of health play in care gaps?

Social determinants, including income, education, housing stability, and access to transportation, significantly influence whether patients can access and follow through with recommended health care services. Patients facing these barriers are more likely to experience care gaps. Understanding these factors helps health care providers design targeted interventions that address the root causes of missed care.

How does addressing care gaps benefit value-based care organizations?

Under value-based care models, reimbursement is tied to healthcare quality metrics and patient outcomes rather than volume of services. By proactively closing care gaps, organizations can improve their HEDIS scores and Star Ratings, reduce costly emergency visits and hospitalizations, and demonstrate measurable improvements in public health outcomes, all of which translate to stronger financial performance and better patient relationships.

Closing the Gaps in Care. Improving Lives

Empower your teams to identify, address, and prevent care gaps across your entire patient population.

Closing the Gaps: Transforming Population Health Management