Want to close gaps? Activate patients in their care.

Two leaders actively engaged in addressing care gaps share how healthcare organizations can activate patients to identify and resolve them.  
Clinical Value-Based Care

Many patients put off medical care during the first year of the pandemic, sometimes at significant risk to their health. Particularly in the early days of the COVID-19 crisis, millions of patients missed treatments and delayed preventive care appointments.

Now, providers are seeing the impact of that missed care on health outcomes.  

Healthcare organizations can and should take action to resolve gaps in care — the difference between the care patients need and the care they actually receive. We spoke with two experts who are actively engaged in addressing gaps in care to learn more about how healthcare organizations can best identify and resolve them.  

Delayed preventive care may worsen outcomes
Although patients most commonly put off preventive screenings during the first year of the pandemic, 4 out of 10 U.S. adults said that, as of June 30, 2020, they had delayed or avoided all medical services, including urgent or emergency treatment (12%) as well as routine care (32%), because they were concerned about COVID-19. However, a more recent analysis in August 2021 by the Kaiser Family Foundation noted persistent lower-than-expected utilization, suggesting that patients may be completely forgoing care, rather than just delaying.

As the Omicron COVID-19 variant continues to disrupt daily life, missed care could have significant repercussions, warns Alicia Cowley, MD, MBA, a hospitalist and Director of Clinical Content at Phreesia. For example, patients with chronic conditions who further delay regular care could experience higher rates of hypertension, high cholesterol and diabetes, among other negative outcomes. Chronic diseases aren’t the only concern—patients also need to stay up to date on routine cancer screenings, since delayed testing could significantly affect their prognosis.

Value-based care success means closing care gaps
Health systems contracted under value-based care agreements should be especially focused on resolving gaps in care since a portion of their revenue is typically based on their ability to keep patients with chronic illnesses as healthy as possible.

“Value-based care is focused on the very things people put on hold during the pandemic,” Cowley said. “Payers are holding health systems accountable for those same gaps in care, and health systems want to take care of them.”

To do so, healthcare organizations operating under managed care and other value-based contracts should focus on consistent, targeted patient engagement. Messaging that emphasizes the importance of staying up to date with routine ambulatory care helps patients stay out of the hospital and avoid unexpected costs.

Assess patient care gaps
Health systems and health plans have an obvious benefit around patient data, but not just from the data they have. There is also much to learn from the absence of data for those individuals who haven’t been in from the year before for routine services, Cowley noted. Because patients may be receiving care elsewhere, healthcare organizations can also find out where gaps in care exist by directly asking patients what services they have missed. Their responses can be gathered via text, email, or phone call or requested during an appointment.

Embedding questions into the automated intake process can also be an effective way to gather information from patients, as it is done at Health First, a health system in central Florida that is making a concerted effort to get its patients caught up on missed care.

To determine where care gaps exist, Health First analyzes data from its electronic health record and payer data. The health system regularly receives data from its payers detailing which patients are up to date on annual health assessments, colon cancer screenings, in-range blood pressure and other preventive care, according to Dana Gresky, PhD, Vice President of Value-Based Care at Health First Medical Group.

Make it easy for patients to catch up on care
Health First uses its data analysis to prioritize digital outreach to those patients who are almost overdue for preventive care, according to Dana Gresky, PhD, Vice President of Value-Based Care at Health First Medical Group. Importantly, these outreach campaigns not only encourage patients to schedule an appointment but also give them the ability to immediately self-schedule an appointment via a link in outreach emails.

Patients who complete medical check-in digitally are also notified if they are due for routine care and given the opportunity to schedule needed services and screenings in the same workflow.

“We’re trying to make it extremely easy for patients to schedule these important appointments once they’re reminded,” Gresky says, noting that the process also allows Health First to determine whether gaps in care actually exist. “We have a fair number of ‘snowbird’ patients who use our services only while they’re in Florida part-time,” she explains. “They may have sought care elsewhere during the warmer months, and they can tell us they’re caught up on care, if that’s the case.”

Healthcare organizations make it easier to resolve care gaps by offering digital self-scheduling to patients so they don’t need to take time out of their day to call their doctor’s office.

“People are busy—they need a way to schedule appointments outside of normal hours,” Cowley said. “The pandemic has really brought to light the need for healthcare to be more patient-centered, not just in care delivery, but also in how people interact with their healthcare providers before and after the visit.”

Hit quality targets by continuously monitoring gaps in care
Despite the challenges of the pandemic, Health First met value-based care benchmarks it established with both commercial and government payers in 2020, and it’s on track to exceed those outcomes for 2021. Gresky advises other healthcare leaders to use data to continuously improve their performance throughout the year.

“Use data to optimize performance, stage the tactics that you plan to use over the course of the year to resolve gaps and debrief regularly on whether your plans were effective,” Gresky said.

As healthcare organizations continue to home in on improving population health, technology can greatly support their efforts, not only in improving outcomes but also by making it easier for patients to proactively take charge of their health.

Even though no one knows what lies ahead with the COVID-19 pandemic, we do know that a significant resurgence of the virus could once again motivate patients to defer care. That’s why getting them the care they need now is a critical goal for 2022.

Targeted engagement tools can help health systems get patients the care they need. Learn how Phreesia helps healthcare organizations identify and resolve gaps in care.