Gaps in Care, like missed or delayed preventive screenings, can harm patient’s health and reduce Medicare quality scores. CircleLink Health’s Gap Closer™ helps care managers identify and close gaps in care to improve patient health and increase revenue.

Here is how Gap Closer can help practices and health systems provide higher-quality care.

Why Gaps in Care Matter

As payers like Medicare shift from paying for volume to paying for value, quality measures have proliferated. Programs like Medicare’s Quality Payment Program/Merit-Based Incentive Payment System and the Medicare Advantage Star Rating system include many measures focused on closing gaps in care. These programs reward practices and health systems that provide timely, appropriate care to their patients.

Gaps in Care are missed opportunities for disease prevention, early detection, and routine monitoring. Measures of Gaps in Care focus on general preventive care strategies (e.g. flu shots and annual wellness visits) and targeted prevention for common conditions (e.g. diabetic eye exams). To improve quality scores and receive bonus payments, practices and health systems must have processes in place to identify and resolve Gaps in Care.

That is why CircleLink Health developed Gap Closer.

How Gap Closer Can Help Increase Medicare Revenue

CircleLink Health’s proven Care Management system for Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) now includes Gap Closer to help improve quality scores and health outcomes. The Gap Closer interface allows practices and health systems to identify critical Gaps in Care that must be closed to improve patient health and quality measure performance. Then, CircleLink RN care coaches, or practice staff, can use Gap Closer to identify patients in need of care and use proven outreach strategies to close those gaps. By using care management resources to address Gaps in Care, Gap Closer helps increase quality scores and while improving patients’ health.

For practices participating in MIPS, Medicare Advantage, or other Medicare quality programs, Gap Closer can increase revenue. Quality bonus payments depend on strong performance in closing Gaps in Care. Gap Closer eases this process by enhancing preventive care efforts in CircleLink’s suite of Care Management software and services. With CircleLink, practices and health systems can get Care Management software plus 100% RN care coaches, Remote Patient Monitoring (RPM) and Gap Closer all in one place.

Key Features of Gap Closer

With Gap Closer, care managers can view all patients’ Gaps in Care at a glance. This helps care managers focus on reaching out to patients with high-priority gaps for follow-up. CircleLink Health’s RN care managers then use clinically appropriate best practices to get patients the care they need.

Gap Closer also includes pre-filled, condition-specific content focused on the Gaps in Care most requested by CircleLink’s providers. These include measures like diabetic eye exams, annual wellness visits, and COVID-19 vaccination and testing measures. This care manager-facing view helps clinicians and their practices keep track of difficult-to-meet quality measures and adjust processes to close Gaps in Care.

Gap Closer includes pre-filled, condition-specific content

Gap Closer also includes conditional pre-filled/intelligent input forms for each Care Gap (See below for A1C). These forms help ease data collection, reduce errors, and make care managers more efficient. These system forms also prompt care managers to close identified Gaps in Care by scheduling appointments or making an alternative, clinically appropriate plan to close the Care Gap.

Close identified Care Caps

Besides patient and condition-level tools, Gap Closer includes population-level data reports. These reports help practices and health system staff see Gaps in Care across their entire patient population. With these reports, care managers, providers, practices, and health systems can track progress toward preventive care and quality measure goals.

Through regular review of population-level data, practices and health systems can maximize quality scores and quality bonuses. More importantly, they can improve population health. Gap Closer’s population-level data reports can also help identify patients or patient groups who continue to have Gaps in Care even after care managers work to close high-priority gaps. Armed with this information, practices and health systems can assess the reasons for persistent Gaps in Care and identify potential solutions and areas for improvement.

Gap Closer Gets Results

CircleLink Health tested a Gap Closer prototype with a major east coast health system. In this pilot project, CircleLink’s RN care managers used Gap Closer to address gaps in care targeted by the MIPS quality measures. CircleLink and Gap Closer increased closure of these Gaps in Care by 25% vs. the MIPS national average.

CircleLink’s team of RN case managers are already using Gap Closer in multiple health systems and group practices. These customers have reported significant progress in closing Gaps in Care, particularly for diabetic eye exams. After the 2021 Medicare quality reporting period comes to a close, CircleLink will release more data on Gap Closer’s proven results.

Call Today to See Gap Closer in Action

Want to see Gap Closer in action? Call CircleLink Health at 209-890-8382 or fill out the online contact form to schedule a one-on-one demo.